THE IMPACT OF DEVOLUTION ON HEALTH CARE

SYSTEMS: A CASE STUDY OF NAIROBI COUNTY

HEALTH FACILITIES

BY

TRUPHENA MAKONJO GIMOI

UNITED STATES INTERNATIONAL UNIVERSITY

SUMMER 2017

THE IMPACT OF DEVOLUTION ON HEALTH CARE

SYSTEMS: A CASE STUDY OF NAIROBI COUNTY

HEALTH FACILITIES

BY

TRUPHENA MAKONJO GIMOI

A Research Project Report Submitted to the Chandaria School of Business in Partial Fulfillment of the Requirements for the Degree

of Masters in Business Administration (MBA)

UNITED STATES INTERNATIONAL UNIVERSITY

SUMMER 2017

ii

STUDENTS DECLARATION

I, the undersigned, declare that this is my original work and has not submitted to any other college,

institution or university other than the United States international university in Nairobi for academic

credit.

Signed: _____________________ Date: ____________________________________

Truphena .M. Gimoi (ID638613)

This project has been presented for examination with my approval as the appointed supervisor.

Signed: _____________________ Date: ____________________________________

Timothy C. Okech, PhD

Signed: _____________________ Date: ____________________________________

Dean, Chandaria School of Business

iii

COPYRIGHT PAGE

Truphena Makonjo Gimoi © 2017

All rights reserved

iv

ABSTRACT

The purpose of this study was to analyze the impact of devolution on healthcare

systems. The study was guided by three research questions namely i) what is the

effect of devolution on health infrastructure? ii) What is the effect of devolution on

access to health services? and iii) what is the effect of devolution on health care

workforce? Stratified sampling technique was used to select respondents based on

cadres in order to have a sample population that is representative. They include

Pharmacists, clinicians, Nurses, medical officers, procurement officers and Hospital

Managers. The population of study was ninety-four public health facilities in Nairobi.

Data was collected using a structured questionnaire, with pilot conducted on a sample

of thirty respondents from Westland’s health facilities was used. Both descriptive and

inferential statistical methods were used to analyze the data. Whereas descriptive

statistics included frequency tables, charts and graphs, inferential statistics including

t-tests, regression and correlation analysis was used to determine relationships

between variables.

The study revealed that devolution had an improvement on health infrastructure.

Medical equipment was in good condition in most facilities and new equipment had

been acquired under the medical equipment scheme such as x-ray machines,

nebulizers, lab equipment among others. In terms of access, it was observed that most

health facilities served an average population of between 5000 to 10,000 people,

which shows a low reach out to the intended population which should be of 30,000

people. Also, of importance to note, was that most of the health facilities had

ambulances for use during emergency services, although inadequate funding for

medicines, equipment and maintenance of buildings was observed. Significant gaps

were also identified in the health care workforce where there was shortage of staff in

health facilities coupled with lack of motivation mechanisms put in place that led to

low productivity.

In conclusion there still exist significant gaps with health infrastructure, especially

need for specialized medical equipment, maintenance of the equipment and the

personnel to operate the equipment. Similarly, under access, there is need for wider

outreach to the population, need to address funding for medicines and other medical

supplies to avoid stock-outs and maintenance of buildings. There were also notable

gaps in health care workforce, with staff shortages in health facilities and staff who

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are demotivated. From the findings the study recommends that equipment should be

maintained in good working condition and counties should consider having

designated units for repair and maintenance of the equipment coupled with personnel

to do the repairs, also, allocate funding for purchase of specialized equipment. Other

recommendations include, allocate more funds for purchase of medicines and

maintenance of buildings, hiring of more workers to address the shortage problem

which can be done by emulating best practices where non-professional people are

hired and trained to offer non complicated procedures such as taking weights. Also,

county healthcare facilities should put in place motivation mechanisms such as risk

allowance, provision of bonuses and time-offs for their staff.

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ACKNOWLEDGEMENT

I am grateful to the almighty God for whom this study could not have been possible

I am greatly indebted to my supervisor Prof Timothy C. Okech for his valuable

guidance throughout the study. My special appreciation goes to my family and friends

for their motivation, prayers and encouragement during the study.

May God bless you all.

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DEDICATION

To my husband Richard Tilak, Son Kibet Kipchumba and daughter Chemutai Tilak

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TABLE OF CONTENT

STUDENTS DECLARATION ............................................................................................... ii

COPYRIGHT PAGE ………………………………………………......................................iii

ABSTRACT ........................................................................................................................... .v

ACKNOWLEDGEMENT …………………………………………………………………...vi

DEDICATION……………………………………………………………………………….vii

LIST OF ABBREVIATIONS ……………………………………………………………….xi

LIST OF TABLES…………………………………………………………………………...xi

LIST OF FIGURES ………………………………………………………………………..xiii

CHAPTER ONE ..................................................................................................................... 1

1.0 INTRODUCTION ...................................................................................................... 1

1.1 Background of the Problem........................................................................................ 1

1.2 Statement of the Problem ........................................................................................... 6

1.3 Purpose of the study ................................................................................................... 7

1.4 Research questions ..................................................................................................... 7

1.5 Importance of the study .............................................................................................. 7

1.6 Scope of the study ...................................................................................................... 8

1.7 Definition of terms ..................................................................................................... 8

1.8 Chapter summary ..................................................................................................... 10

CHAPTER TWO................................................................................................................... 11

2.0 LITERATURE REVIEW ......................................................................................... 11

2.1 Introduction .............................................................................................................. 11

2.2 Effect of devolution on health facility infrastructure ............................................... 11

2.3 The Effect of Devolution on Access to Health Services. ......................................... 16

2.4 Effect of Devolution on Health Care Work Force ................................................... 20

2.5 Chapter Summary ..................................................................................................... 24

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CHAPTER THREE ............................................................................................................... 25

3.0 RESEARCH DESIGN AND METHODOLOGY .................................................... 25

3.1 Introduction .............................................................................................................. 25

3.2 Research Design ....................................................................................................... 25

3.3 Population and Sampling Design ............................................................................. 26

3.4 Data Collection Methods .......................................................................................... 27

3.5 Research Procedures ................................................................................................ 28

3.6 Data Analysis Methods ............................................................................................ 28

3.7 Chapter Summary ..................................................................................................... 28

CHAPTER FOUR ................................................................................................................. 30

4.0 RESULTS AND FINDINGS ................................................................................... 30

4.1 Introduction .............................................................................................................. 30

4.2 Response Rate and General Information .................................................................. 30

4.3 The Effect of devolution on health Infrastructure .................................................... 34

4.4 The Effect of Devolution on Access to Health Services .......................................... 40

4.5 The Effect of Devolution on Health Care Workforce .............................................. 53

4.6 Chapter summary ..................................................................................................... 59

CHAPTER FIVE ................................................................................................................... 60

5.0 SUMMARY, DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS 60

5.1 Introduction .............................................................................................................. 60

5.2 Summary of findings ................................................................................................ 60

5.3 Discussion ................................................................................................................ 61

5.4 Conclusion................................................................................................................ 63

5.5 Recommendations .................................................................................................... 64

REFERENCES ...................................................................................................................... 66

APPENDICES ....................................................................................................................... 70

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LIST OF ABBREVIATIONS

DHMT-District Health Management Team

DMOH-District Medical Officer of Health

GoK- Government of Kenya

HRH- Human Resources for Health

MoH- Ministry of Health

NGO- Non Governmental Organizations

SPSS- Stastistical Package for Social Sciences

SWAp- Sector-Wide Approach in Health

TA- Transition Authority

UHC- Universal Health Coverage

WHO- World Health Organization

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LIST OF TABLES

Table 1: Current status of health infrastructure….............................................................… 14

Table 2: Nairobi County Health Facilities…………………………………………………. 28

Table 4.1: Departments interviewed………………………………………………………. 32

Table 4.2: Position of respondents in the organization…………………………………..… 32

Table 4.3: The level of education of the respondents…………………………………..…… 33

Table 4.4: The gender of the respondents…………………………………………………. 33

Table 4.5: The age of the respondents…………………………………………………..….. 34

Table 4.6: The years of service in the organization……………………………………..….. 34

Table 4.7: Difference between gender and position held………………………………….. .34

Table 4.8: Independent samples test…………………………………………………….….. 35

Table 4.9: Clean toilets available for staff and patients………………………………... ….. 36

Table 4.10: Availability of protected placenta pit……………………………………… ….. 36

Table 4.11: Disposal of sharp wastes……………………………………………………….. 36

Table 4.12: Availability of a generator…………………………………………............ ….. .37

Table 4.13: Water supply………………………………………………………..............….. 37

Table 4.14: Communication Facilities……………………………………….…………..…. 38

Table 4.15: Email /internet facility……………………………………………................ …38

Table 4.16: New equipment…………………………………………………………….. . …39

Table 4.17: Transport used during emergencies………………………………………... . …40

Table 4.18: Correlation between budget for the year and state of medical equipment… ..... 41

Table 4.19: Transport used by patients referred from other facilities…………………... .... 42

Table 4.20: Correlation between catchment area and time taken to get to facility……… .. .44

Table 4.21: Correlation between source of funds and budget……………………………. .. 46

Table 4.22: Adequate funding allocated for medicine……………………………………... 47

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Table 4.22: Adequate funding allocated for equipment…………………………………..47

Table 4.23: Adequate funding allocated for maintaining buildings………………………47

Table 4.24: Designated unit for repair and maintenance of equipment…………………..48

Table 4.25: Unit for repair and maintenance predicts the state of medical equipment…...48

Table 4.26:Offer basic emergency obstetric care…………………………………………49

Table 4.27: Emergency obstetric care that require specialists……………………………50

Table 4.28: Free maternity services………………………………………………………50

Table 4.29:Labour ward…………………………………………………………………..50

Table 4.30: Offer routinely inpatient care………………………………………………...50

Table 4.31: Have beds for overnight observation………………………………………...51

Table 4.32: Number of staff………………………………………………………………55

Table 4.33: Adequately staffed…………………………………………………………...55

Table 4.34: Continual medical education…………………………………………………55

Table 4.36: Mechanisms used for staff motivation……………………………………….57

Table 4.37: Receive promotion …………………………………………………………..58

Table 4.38: Criteria for promotion………………………………………………………..58

Table 4.39: Correlation size of the catchment population and total number of staff…….60

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LIST OF FIGURES

Figure 4.1: State of medical equipment…………………………………………………...39

Graph 4.1: New equipment bought since county government came into place…………..40

Figure 4.2: Catchment population………………………………………………………...42

Figure 4.3: How much time it takes patients to get to facility……………………………43

Figure 4.4: Source of funding…………………………………………………………….45

Figure 4.5: Budget for the year…………………………………………………………..46

Graph 4.2: Number of inpatient beds………………………………………………….....52

Figure 4.6: Condition of laboratory………………………………………………………53

Figure 4.7: Replenishment of medical supplies……………………………………….....53

Figure 4.8: Store audit…………………………………………………………………....54

Graph 4.3: Medical education received…………………………………………………..56

Figure 4.9: Frequency of Appraisals………………………………………………….......57

Graph 4.4: Areas of Improvement………………………………………………………...59

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CHAPTER ONE

1.0 INTRODUCTION

1.1 Background of the Problem

Devolution entails transfer of certain powers and responsibilities and resources from the

central government to popularly elected regional or local governments that are established

by law (Bosire, Cottrell Ghai & Pal Ghai, (2015). Devolution is the statutory delegation of

powers from the central government of a sovereign state to govern at a sub-national level,

such as a regional or local level. It is also a form of administrative decentralization or the

transfer of authority and responsibility from central to lower levels of government for a

range of public functions including health care (Williamson & Mulaki, 2015; Okech,

2017). Devolved territories have the power to make legislation relevant to the area

meaning that the units have clear and legally recognized geographical boundaries over

which they exercise authority and within which they perform their functions in their

respective jurisdictions (Okech, 2017). Worldwide, there has been a trend in the devolution

of authority in healthcare whereby the authority that was often sitting with one central

Ministry or Department of Health devolved over time (KPMG, 2015; Okech, 2016).

When governments devolve functions, they transfer authority for decision-making,

finance, and management to quasi-autonomous units with corporate status (World Bank,

2014). Depending upon the functions and authorities transferred, decentralization

processes can involve one or more categories (Okech, 2017).In Kenya, following the

promulgation of the new constitution in 2010, a devolved system of governance with two

levels of government - National and County government was created (Okech & Lelegwe,

2016; Okech, 2017). At national level, health leadership is provided by the Ministry of

Health (MOH) whose key mandates include development of national policy; provision of

technical support at all levels; monitoring quality and standards in health services

provision. Others include provision of guidelines on tariffs for health services, conducting

studies required for administrative or management purposes (Okech, 2017). The Ministry

is also mandated with the development of national policy that guides the recruitment,

placement, training and remuneration of all health workers in the country; monitoring

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quality and standards in health services provision, and the charges for the various services

by health care providers. Provision of necessary legal framework for ensuring a

comprehensive and people driven health care delivery is also the responsibility of the

Ministry of Health (GoK, 2010; Okech, 2016; Okech, 2017).

In a devolved system, local governments have clear and legally recognized geographical

boundaries over which they exercise authority and within which they perform public

functions (World Bank, 2012). Despite decades of strong advocacy for the decentralization

of health administration, health care systems decisions are taken in central divisions of the

ministries of health in most world economies including African countries. These decisions

are then conveyed top-down through the provincial (or regional) health administration to

the operational services at district level: hospitals, health centers and vertical programme

centers (Blaise & Kegels, 2004).

Since independence in 1963, centralization has been at the core of Kenyan governance,

with power concentrated in the capital. As a result, Kenya has been marked by spatial

inequalities during this period of time. It is against this backdrop that healthcare devolution

is taking place. Article 174 of the Kenya Constitution clearly articulates the rationale

behind devolution as, among other reasons, self-governance, economic development and

equitable sharing of national and local resources. Kenya’s health infrastructure includes the

national teaching hospital, provincial hospitals, district and sub district hospitals, health

centers, and dispensaries, as well as a host of other operators within the private, non-

governmental, and traditional sectors. The system is a hierarchical-pyramidal organization

comprising five levels, the lowest being the village dispensary and the Kenyatta National

Hospital at the apex (Wamai, 2009).

Centralized health systems have been criticized for regional and provincial discrepancies in

the health service distribution, disparities in resource allocations, and inequitable access to

quality health services. Over the past decade, Kenya has committed to reforms to

decentralize the country’s health management system, to increase decision-making power

for resource allocation and service delivery at the district and facility levels and to allow

for greater community involvement in health management. Through gradual reforms

outlined in the two Health Sector Strategic Plans, District Health Management Boards and

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District Health Management Teams (DHMTs) have taken on responsibilities for facility-

level operations within their districts (Ndayi et al., 2009).

The Kenya Health Policy Framework has been the basis for the health development agenda

in Kenya since 1994. The framework emphasizes “quality health care that is acceptable,

affordable and accessible to all.” The implementation of this framework was divided into

two five-year strategic plans: the National Health Sector Strategic Plan 1 (MOH 1999) and

the National Health Sector Strategic Plan II (MOH 2005). The objectives of the National

Health Sector Strategic Plan I (NHSSP I, 1999-2004) were to: strengthen governance,

improve resource allocation, decentralize health services and management, shift resources

from curative to preventive and Primary Health Care services, provide autonomy to

provincial and national hospitals and enhance collaboration with stakeholders under a

Sector-Wide Approach in Health (SWAp) modality among others(KHSA, 2010).

The mandate for supervision, formulation of policies, establishment and enforcement of

standards, and mobilization of resources for health care rests with the Ministry of Health.

Lower levels of administrations called districts, were responsible for delivering health

services and implementing health programs. Under the decentralization strategy, districts

form the central pillars of the public health system. Management of healthcare at the

district level is headed by a District Medical Officer of Health (DMOH) appointed by the

Ministry of Health. The DMOH is supported by a District Health Management Board

(DHMB) comprising officials appointed by the MOH and from local areas, and a

professional unit, the District Health Management Team (DHMT). The DHMT prepares

technical advisories and the District Health Plan in consultation with local health actors

and the DHMB.The provinces and districts vary in geographical size and population, as

well as overall health and socio-economic indicators (Wamai, 2009).

In a renewed effort to improve health service delivery, the Ministry of Health and

stakeholders reviewed the NHSSP-I service delivery system in order to devise a new

strategy for making it more effective and accessible to as many people as possible.

(NHSSP II 2005 – 2010) was designed to reduce health inequalities and to reverse the

downward trend in health-related impact and outcome indicators that had been noted

during the implementation of the NHSSP-I. Its strategic objectives were to: increase

equitable access to health services, improve quality and the responsiveness of services in

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the sector, enhance the regulatory capacity of MOH, improve the efficiency and

effectiveness of service delivery and foster partnerships in improving health and improve

the financing of the health sector. Key innovations of the NHSSP II include the definition

of the Kenya Essential Package for Health (KEPH) and the inclusion of the community

level as part of the service delivery units (GoK, 2010).

The objectives of the KEPH are fundamental to the overall policy objectives of NHSSP II.

Specifically, KEPH intends to: Increase access to health services by targeting part of its

interventions at the community level and at poor deprived areas and groups (poor districts

and sub-districts, pastoralists): Integrate the different programmes towards the client;

Enhance the promotion of individual and community health; Improve quality of service

delivery by improving the responsiveness of health workers and changing their prevailing

attitudes towards clients (GoK, 2010).

The Government of Kenya developed Vision 2030 as its new long-term development plan

for the country. The aim of the Kenya Vision 2030 is to create “a globally competitive and

prosperous country with a high quality of life by 2030” through transforming the country

from a third world country into an industrialized, middle income country. To improve the

overall livelihoods of Kenyans, the country aims to provide an efficient integrated and high

quality affordable health care system. Priority will be given to prevented care at

community and household level, through a decentralized national health-care system. With

devolution of funds and decision-making to county level, the Ministry headquarters will

then concentrate on policy and research issues. With the support of the private sector,

Kenya also intends to become the regional provider of choice for highly-specialized health

care, thus opening Kenya to “health tourism”. Improved access to health care for all will

come through: provision of a robust health infrastructure network countrywide; improving

the quality of health service delivery to the highest standards; promotion of partnerships

with the private sector; providing access to those excluded from health care for financial or

other reasons. The country recognizes that achieving the development goals outlined in

Vision 2030 will require increasing productivity. The health sector is expected to play a

critical supportive role in maintaining a healthy workforce which is necessary for the

increased labour production that Kenya requires in order to match its global competitors.

Health is, therefore, one of the key components in delivering the social pillar ‘Investing in

the People of Kenya’ for the Vision 2030 (GoK, 2008). In August 2010, Kenya adopted a

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new constitution that introduced a new governance framework with a national government

and 47 counties. This was a radical departure from the highly centralized form of

governance that had been in place since independence, but resulted in political and

economic disempowerment and unequal distribution of resources (World Bank, 2012).

The highly centralized government system also led to the weak, unresponsive, inefficient,

and inequitable distribution of health services in the country (Ndavi et al., 2009). It is

expected that a devolved health system will improve efficiency, stimulate innovation,

improve access to and equity of services, and promote accountability and transparency in

service delivery (Bossert, 1998). However, the complexity of Kenya’s devolution

framework has generated concern that services could be disrupted if the transition is

managed poorly.

Under the new framework, responsibility for health service delivery is assigned to the

counties while policy, national referral hospitals, and capacity building are the national

government’s responsibility (Constitution of Kenya [COK], 2010).The framework for the

transfer of these functions is in the Transition to Devolved Government Act, 2012. The

health service delivery function was formally transferred to counties on August 9, 2013,

and one-third of the total devolved budget of Ksh 210 billion was earmarked for health in

the 2013/2014 budget following the transfer Barker, Mulaki, Mwai, &Dutta (2014).

The objectives of devolution, include the following: The promotion of democracy and

accountability in delivery of healthcare; Fostering of seamless service delivery during and

after the transition period; Facilitating powers of self-governance to the people and

enhancing their participation in making decisions on matters of health affecting them;

Recognizing the right of communities to manage their own health affairs and to further

their development; Protection and promotion of the health interests and rights of minorities

and marginalized communities, including informal settlements such as slum dwellers and

under-served populations; Promotion of social and economic development and the

provision of proximate, easily accessible health services throughout Kenya; Ensuring

equitable sharing of national and local resources targeting health delivery throughout

Kenya; Enhancing capacities of the two levels of governments to effectively deliver health

services in accordance with their respective mandates; Facilitating the decentralization of

state organs responsible for health, their functions and services from the Capital of Kenya

6

;Enhancing checks and balances and the separation of powers between the two levels of

government in delivery of health care (GoK, 2014).

The two levels of governments, have specific functions assigned to them which are as

follows: National government: leadership of health policy development; management of

national referral health facilities; capacity building and technical assistance to counties;

and consumer protection, including the development of norms, standards and guidelines.

County governments: responsible for county health services, including county health

facilities and pharmacies; ambulance services; promotion of primary healthcare; licensing

and control of undertakings that sell food to the public; cemeteries, funeral parlors and

crematoria; and refuse removal, refuse dumps, and solid waste disposal(COK, 2010).

1.2 Statement of the Problem

The Constitution of Kenya was formally promulgated into law on 27th August 2010. The

new constitution introduced major changes in the country’s governance framework. A key

departure from the earlier system of governance is the shift from a highly centralized to a

decentralized governance framework, comprising of two levels of government the national

government and 47 county governments. Previously, the Executive, through the President

and the Cabinet, exercised significant political, administrative and fiscal power control

over both the national and sub-national governments. This changed with the establishment

of the county governments. Devolution as envisaged in the Constitution of Kenya provides

for sharing of political, administrative and fiscal responsibilities between the national and

the county governments. It is the assignment of these three dimensions of power that

determine the level of devolution (Mwenda, 2010).

Barker et al (2014) found that devolution came with fears of disruption of services that are

largely linked with concerns about the counties’ readiness to deliver services. The

Transition Authority (TA) set specific timelines and criteria for the assessment of county

preparedness to take up devolved functions. The criteria are however considered to be

generic, making it difficult to determine whether counties are ready to offer the health

services under their ambit. In addition, political pressure from the newly elected county

governments led to a bulk transfer of functions, irrespective of the counties’ level of

preparedness.

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Considering that a strong, efficient, well-run health system and a sufficient capacity of

welltrained, motivated health workers among other pillars are important in realizing

universal coverage, the paper aimed to fill the knowledge gap of the country’s health

infrastructure, access and healthcare workforce and how these impact on health care

delivery with devolution.

1.3 Purpose of the study

The purpose of this study was to analyze the impact of devolution on health care

systemsby health facilities in Nairobi County.

1.4 Research Questions

The study was guided by the following research questions:

1.4.1 What is the effect of devolution on health infrastructure?

1.4.2 What is the effect of devolution on access to health services?

1.4.3 What is the effect of devolution on health care workforce?

1.5 Importance of the study

Due to the increasing need to meet the millennium development goals on health, the study

will benefit the following stakeholders among others:

1.5.1 National Government

National government has stated intentions of improving health care. The Kenya Health

Policy 2014–2030, goal is attainment of the highest standard of health in a manner

responsive to the needs of the Kenya population. The study will help measure the goal and

assess areas of improvement.

1.5.2 County government

The primary outcomes that are common decentralization goals that include improved

service delivery (efficiency, equity,), improved governance (deeper and more inclusive),

poverty reduction, improved livelihoods, and increased stability. The study will enlighten

the county government on whether it has met its primary outcome and areas that need

improvement with regard to county health facilities. If these outcomes are met it will

enhance governance and well-being and reduce conflict.

8

1.5.3 Communities

The study will edify communities to hold leaders and those in charge of implementation

accountable, by improving public service delivery through efficient resource allocation,

enhancing accountability, reducing corruption and improving cost recovery. It will also

give insight on progress of devolution in counties and communities can express a voice

that may put pressure on institutions to take account of failings in accountability.

1.5.4 Management and staff of Health facilities

The study will be important to the management and staff of health facilities because it aims

to create awareness to the areas that need improved delivery and ensure primary health

care to the people is improved.

1.5.5 Academic Research

The study will make a significant contribution to the growing body of research on the

impact of devolution on development.

1.6 Scope of the study

The study focused on Nairobi county health facilities. Respondents selected were

Pharmacists, clinicians, Nurses, medical officers, procurement officers and Hospital

Managers. The study began in January 2016 with the introduction, literature review,

research design and methodology and second part of data collection results and findings,

summary discussions, conclusions and recommendation was completed in May 2017.

1.7 Definition of terms

1.7.1 Devolution

Is the transfer of certain powers and responsibilities and resources from the central

government to popularly elected regional or local governments that are established by law

(Bosire, CottrellGhai and PalGhai, 2015).

1.7.2 Decentralization

Decentralization involves assigning public functions, including a general mandate to

promote local well-being, to local governments, along with systems and resources needed

to support specific goals (Bosi, Loffler &Smoke, 2013).

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1.7.3 Political decentralization

This involves the transfer of political authority to the local level through the establishment

of sub-national governments as well as electoral and political party reforms.

1.7.4 Administrative decentralization

This refers to the full or partial transfer of functional responsibilities to the sub-national

units of governance. Functions that are typically transferred to the sub-national units

include health care services, garbage collection, among others.

1.7.5 Fiscal decentralization

This refers to the transfer of financial authority to the sub-national governments by

reducing the conditions on the intergovernmental fiscal transfer of resources and granting

sub-national units greater authority to generate their own revenue (Mwenda, 2010)

1.7.6 Primary health care

Is defined as essential health care; based on practical, scientifically sound, and socially

acceptable method and technology; universally accessible to all in the community through

their full participation; at an affordable cost; and geared toward self-reliance and self-

determination (WHO &UNICEF, 1978).

1.7.7 De-concentration

De-concentration is transfer of administrative responsibilities to nonelected central

government officials at the regional offices.

1.7.8 Delegation

Transfer of managerial responsibility to a unit outside the usual central government

structure (Mwenda, 2010).

1.7.9 Health infrastructure

Relates to all the physical infrastructure, non-medical equipment, transport, and technology

infrastructure (including ICT) required for effective delivery of services (GoK, 2014)

1.7.10 Health care services

The prevention and management of disease, illness, injury, and other physical and mental

impairments in individuals delivered by healthcare professionals through the healthcare

10

system; they can either be routine health services or emergency health services (KHP,

2014-2030).

1.7.11 Health care work force

The workforce that delivers the defined healthcare services. The workforce includes all

those whose prime responsibility is the provision of healthcare services, irrespective of

their organizational base (public or non-public) (GoK, 2014).

1.7.12 Health care system

The mechanism to deliver high-quality healthcare services to all people when and where

they need them (GoK, 2014).

1.8 Chapter summary

This chapter has introduced the problem and the purpose of the study. The following areas

of discussion have been included; Background of the problem; statement of the problem;

Purpose of the study; Research Questions; Importance of the Study; Scope of the study and

definition of terms.Chapter two presents a review of the literature that is relevant to the

objectives of the study, while chapter three present the research methodology used.

11

CHAPTER TWO

2.0 LITERATURE REVIEW

2.1 Introduction

This chapter provides literature on devolution of health care. It also presents general

assessment ondevolution of health care with both local and international experiences.This

is organized based on research questions as outlined in chapter one.

2.2 Effect of devolution on health facility infrastructure

A country’s healthcare system may be analyzed on the basis of the healthcare

infrastructure, the players and their roles, and financing mechanisms. Each of these

features of the system in Kenya and their utilization are discussed.

2.2.1 Health Infrastructure

To realize universal coverage, a strong, efficient, well-run health system is necessary

(WHO, 2010). This in turn requires a robust health infrastructure in terms physical

infrastructure, medical equipment, communication and ICT, Transportation. Kenya’s

health care provision and implementation infrastructure include the national teaching

hospital, provincial hospitals, district and sub-district hospitals, health centers, and

dispensaries, as well as a host of other operators within the private, non-governmental, and

traditional/informal sectors. The system is a hierarchical-pyramidal organization

comprising five levels, the lowest being the village dispensary with Kenyatta National

Hospital (KNH) at the apex. The health sector requires establishment of an effective

organization and management system to deliver on the KEPH.

The many years of neglect caused by budgetary insufficiencies has reduced most facilities

to a sorry state that requires rehabilitation before a maintenance programme can be

instituted. Some of Kenya’s health facilities lack adequate premises for priority

interventions, such as delivery rooms, maternity, laboratories, theatres, etc. Public health

technicians who were trained to maintain physical infrastructure are not used for that

purpose. Similarly, because of low budgetary allocations to health, the few available

12

resources have been fully charged to pharmaceutical and non-pharmaceutical commodities.

As a result, equipment has not been replaced for a long period, compromising the quality

of care provided. Staff skilled in maintenance are rarely available at the district levels and

below. Where they exist, they are not supported by the necessary tools, consumables or

financial resources. General maintenance capacity has therefore been eroded over the

years. Keeping the health infrastructure and the equipment in good condition would

undoubtedly change the public’s perception of good quality care and this in turn would

encourage people to use the available health services (GoK, 2005).

With establishment of Counties, the National level prioritize establishment of a minimum

number of health facilities, based on the expected services as defined in the KEPH.

According to the most recent health management information system (HMIS) data, there

are over 5,000 health facilities across the country operated by three owner systems, with

the government running 41% of the facilities, non-governmental organizations (NGOs)

15%, and private businesses 43%. The government owns most of the hospitals, health

centers, and dispensaries, while clinics and nursing homes are entirely in the hands of the

private sector. Health facilities are unevenly distributed across the country. For instance,

the best-off Central Kenya has about twice the number of facilities per population as the

worst-off provinces (Nyanza and Western). Central, Coast, and Eastern regions have better

ratios than the national average. On the other hand, Nyanza has a higher number of

hospital beds and cots per 100,000 population than Central. Northeastern and Eastern

regions have the worst ratios of hospital beds and cots per 100,000 population, while Coast

has the best (144, 145 and 274, respectively). Because of their relatively small

geographical sizes, Nairobi followed by Central has the minimal distance to a health

facility. (Wamai, 2004; MoH, 2010; MoH, 2015).

The available infrastructure has however continued to impact negatively on the care as

well as the ability to retain some key health personnel especially, specialized health

workers in the public service. Cases where for instance specialized doctors complained of

underutilization of their skills have been experienced with many opting to join private

practice or resigning to pursue further studies. If the situation is not addressed, in the end,

patients are likely to be left with no option but to either seek services of less qualified

health personnel or providers or alternative health care services whose quality may not be

guaranteed. Worse, others may seek services from private facilities which may be

13

relatively expensive thereby negating the expected gains of financial risk protection

currently being pursued under the enhanced National Hospital (Okech, 2016).

2.2.2 Current Status of health infrastructure

Many primary care facilities are not offering comprehensive package of primary care

services. Facility investments not matched with other investments (HRH, commodities,

etc.), affecting functionality after completion of investments. Limited investment in

maintenance of physical infrastructure ongoing supervision process monitoring

maintenance of physical infrastructure in hospitals.

Infrastructure investment focus has been on establishment of 201 model health Centre’s

under the economic stimulus package while more than 80 hospital projects are at various

stages of completion. There are, however, significant challenges particularly in relation to

equity in distribution of infrastructure, as shown in the Table 1

14

Table 3: Current status of health infrastructure

Area

Current Status

Physical

infrastructure

Significant ongoing projects, focusing on establishment

of 201 model health Centre’s, and expansion of hospital

infrastructure in 80 hospitals

Many primary care facilities not offering comprehensive

package of primary care services

Facility investments not matched with other investments

(HRH, commodities, etc.), leading affecting functionality

after completion of investments

Limited investment in maintenance of physical

infrastructure – ongoing supervision process monitoring

maintenance of physical infrastructure in hospitals

Communication

and ICT equipment

ICT equipment supplied to all public / FBO facilities

Communication equipment (telephones) available in all

hospitals

Radio equipment provided to all facilities in Arid / Semi-

Arid areas of the Country

Limited investment in maintenance of communication

equipment

Medical equipment

Investments in medical equipment ongoing in selected

hospitals

Lack of comprehensive, coordinated investment, with gaps

in some facilities still existent

Limited investment in maintenance of medical equipment

Transport Purchase of ambulances ongoing, at hospitals, and model

Health Centres

Still significant gaps in utility vehicle availability (some

ambulances also used as utility vehicles as a result)

MOH undertaking some measures to enhance transport

possibilities in the sector such as: outsourcing of certain

activities to the private sector, e.g. courier companies to

collect/deliver stocks/specimens, taxi companies for

referral in very rural areas with appropriate reimbursement

and ambulances for bigger hospitals

Limited maintenance investment

Source: KHSSP, 2013-2017

2.2.3 Health Care Financing System

The health sector in Kenya relies on several sources of funding: public (government),

private firms, households and donors (including faith based organizations and NGOs) as

well as health insurance schemes. Consumers are the largest contributors, representing

15

approximately 35.9 percent, followed by the government of Kenya and donors at 30

percent each. Over the past few years, government financing as a percentage of GDP has

been consistent at slightly above four percent. As a signatory to the 2001 Abuja

Declaration, Kenya committed to allocating at least 15 percent of its national budget to

health. Not only is Kenya spending a relatively low amount as a percentage of GDP on

healthcare, but the allocation of funds to public facilities has been uneven. According to a

2011 Healthy Action report, secondary and tertiary facilities have historically been

allocated 70 percent of the health budget. The same report notes that allocation of funds to

primary care facilities has been “poor” − this despite the significant role these facilities

play as the first point of contact in the provision of healthcare services (KPMG, 2015)

The share of government spending in the government budget depicts general

underfinancing of publicly provided for services, even though for some services especially

for non-communicable diseases, the gap is bridged by donors (Bultman, 2014; P4H, 2014).

In the Health Financing Strategy of 2010, the government emphasized social health

protection to all Kenyans by introducing social solidarity mechanisms founded on

complementary principles of social health insurance and tax financing for purposes of

financial protection of the poor and other vulnerable groups. In order to achieve the set

objectives, the government reiterated its commitment to amend the NHIF Act for purposes

of enhancing access, and broadening benefit package. In the new constitution promulgated

in 2010, the government provided the necessary legal framework for ensuring a

comprehensive and people driven health care delivery aimed at enhancing access to quality

and affordable health care (Okech & Lelegwe, 2016).

Recent initiatives of “Beyond Zero Tolerance” campaign for expectant mothers, children

and breast cancer are some of the latest efforts towards UHC. This has seen many

stakeholders pull resources towards the initiatives although there are still no reliable

statistics to inform policy dialogue on the pack of the initiatives. Whereas this is positive

step in the right direction, there is lack of policy to support the initiative to ensure

sustainability in the event of political regime change, which is undoubtedly expected in a

democratic society (Okech & Lelegwe, 2016).Unfortunately, limitations in implementing

an overall healthcare financing strategy has hindered effective planning, budgeting and

provision of health services. The health system has also struggled with stagnant or

16

declining budgets for health, system inefficiencies, persistently poor service quality and

lack of equity (Nyakundi, Teti, Akimala, Njoya, Brucker, Nderitu & Changwony, 2011).

Future planning needs to recognize that “reversing the trends” cannot be achieved by the

government health sector alone. Active involvement and partnership with other

stakeholders in the provision of care should be intensified. The goal should be a

functioning health system that relies upon collaboration and partnership among all

stakeholders, and whose policies and services have an impact on health outcomes. The

system should encompass a sector-wide approach and emphasize flexibility for rapid

disbursement and constant monitoring of budgetary resources.

‘Health Financing: The Case of RH/FP in Kenya’ recognizes that the State budget is the

most concrete declaration of a government’s national priorities. Budgets express

government commitment to a policy and indicate the level of priority assigned to it. It is

hoped that improved budget transparency will increase public engagement in the budget

process. This will in turn enhance pro-poor budget policies, allocations and outcomes,

(Nyakundi et al., 2011).

2.2.4 Challenges of Funding

Kenya faces several key challenges in health financing. First, access to services for

individuals and households is fragmented by coverage scheme, while the poor and

vulnerable are largely excluded. Second, the fragmentation of health financing schemes

also brings inefficiencies in service provision and investments. Third, a diverse set of

challenges exist that are related to health systems and public governance issues; key among

these are the lack of an effective quality assurance mechanism and ineffective corporate

governance and accountability mechanisms, which has led to a trust-deficit in Kenyan

health financing institutions. All areas need to be addressed urgently to make significant

progress towards Universal Health Coverage (UHC) (Bultman, 2014).

2.3 The Effect of Devolution on Access to Health Services.

Universal health coverage ensures that all people use the promotive, preventive, curative,

rehabilitative and palliative health services they need, of sufficient quality to be effective,

while also ensuring that the use of these services does not expose the user to financial

hardship has continued to dominate debate in health care (WHO, 2010). This embodies

three related objectives namely i) equity in access to health services so that those who need

17

the services should get them, not only those who can pay for them; ii) that the quality of

health services is good enough to improve the health of those receiving services; and

finally iii) financial risk protection which aims at ensuring that the cost of care does not put

people at risk of financial hardship (WHO, 2010)

Approximately 78 percent of Kenyans live in rural areas, yet a disproportionate share of

healthcare facilities are located in urban areas. Those in rural areas often have to travel

long distances, often on foot, to seek care. According to the World Bank, the index of

access to health services (measuring the share of newborns delivered at a health facility) in

Kenya, speaks volumes to this disparity. For example, over eight in ten children born in

Kirinyaga County, which is located in the central part of the country, are delivered in a

health facility. In Wajir, which is located in one of the most remote and marginalized

regions of the country, one child in twenty is born in a health facility (KPMG, 2013)

2.3.1 Access to Health Services in Kenya – Challenges in Risk Pooling

Financial access to health care services is a serious problem in Kenya. While average total

health expenditure (THE) per Kenyan at USD 42.2 in 2009/10 was sufficient to buy a basic

package of essential health services, there is strong variation around this mean. Out-of-

pocket spending was 25% of THE, showing that many Kenyans cannot rely on equitable

pre-paid financing mechanisms (MOH: NHA 2009/10). In fact, nearly 15% of Kenyans

spent more than 40% of non-food expenditure on health care. Health care is thus a major

source of financial distress for Kenyans. The small share of the health sector in the

Government budget (in 2009/10 only 4.6%) points to a general underfinancing of publicly

provided services, even though for some services (especially HIV/AIDS and Malaria)

some of the gap is made up by spending by development partners (MOH). This is related

to the co-existence of several different coverage schemes. The main ones among these are

the GOK free-care initiatives at primary health care facilities (dispensaries and health

centres) and for free maternal care (esp. deliveries) at higher levels, GOK subsidized

access for other care at referral levels, the National Hospital Insurance Fund (NHIF), as

well as Private Health Insurance (PHI). Some small Community Based Health Insurance

also exists. The existing schemes are isolated and are not connected through financial or

risk equalization mechanisms (P4H, 2014)

18

In 2013, the government announced the abolished user fees at primary health care facilities

and introduced free maternal health care services in public health facilities. This initiative

may be considered a populist policy meant to enhance access to quality care, especially the

poor and other vulnerable groups, its implementation was technically unattainable. The

concern was that at the time, the initiative lacked technical and necessary legal and

operational policies. Technical input to inform the policy initiative is necessary otherwise

the intended objectives may remain unattainable. For instance, following the policy

pronouncement, cases of delays in the disbursement of funds to counties have been

common with a few opting for bank overdrafts to meet operational expenses

notwithstanding the embedded charges. As noted earlier, a system for financing health

services is pivotal in UHC and if not carefully addressed, will negate the realization of

UHC. Cases of stock outs of drugs and other medical supplies, poor maintenance of

equipment, lack of transport, and medical facilities have continued to be experienced in

many public health facilities countrywide (Okech & Lelegwe, 2016).

Access to health services is very unequal and the poor are currently financially excluded

from access to many services. Devolution adds to the complexity, as Counties are now

expected to finance health service provision for primary and secondary care services from

their block grant allocation. Access to publicly provided services (the “free care” and

subsidized / “co-payment categories”) therefore depends on the budget allocations at

County-level, which further fragments financing of health services and hinders equal

access to care(Bultman, 2014).

2.3.2 Improving Access to Kenya Essential Package for Health (KEPH)

According to the Kenya Health Sector Strategic and Investment Plan (KHSSP), July2013-

June 2017 access is a measure of the ability of a person/community to receive available

services. It is a pre- requisite to high utilization of health services as it brings services

closer to the people as well as makes them cheaper. Additionally, access is influenced by

geographic, economic and socio-cultural factors as barriers to care. Poor distribution of

facilities, poor public transport, weak referral systems, insufficient community health

services and weak collaborations with other service providers have perpetuated poor

geographical access to health services (GoK,2013).

There are imbalances in geographical distribution of health facilities in terms of the

numbers and types of facilities available. Some areas have disproportionately more

19

facilities than others. Consequently, while the average distance covered to reach the

nearest health facility is reasonable (within 5 km for medical services, and 2.5km for

public health services as recommended by WHO), there are under-served areas in the

Country, particularly in the Northern Counties of Isiolo, Turkana, Mandera, West Pokot,

Marsabit, Samburu, Wajir, and Garissa.

Economic access constraints, affordability of health services also hinder access to services.

These include low house- hold income, low prioritization of health at household level and

low allocation of resources by the state to the health sector. Because of the high level of

poverty in Kenya, most households cannot afford to pay for health services. Where there is

some household income, health is not given priority. On its part, the government is

required to achieve the commitment in the Abuja Declaration to allocate 15% of

government expenditure budget to health. The measures include introduction of the

National Health Insurance Fund, review of the cost sharing strategy, promotion of

community pre-payment schemes and development of criteria for allocating public funds.

Socio-cultural barriers associated with low literacy levels, religious beliefs and gender bias

hinder access to health services, especially by women, children, adolescents, the disabled

and other vulnerable groups. Recognizing this problem, the government has to make the

provision of health services more humane, compassionate and dignified. Targeted

measures include ensuring privacy in the course of service delivery, especially for

women(WHO, 2015).

2.3.3 Kenya’s Improvement on Delivery of Primary Health Services in a

Devolved Health System

Several challenges in delivery of primary health care services still persist in Kenya. As

done by several other low and middle income countries, Kenya can get better value for

money by first focusing on making existing primary health facilities functional to deliver

quality health services. While the county fact sheets suggest that over a tenth of the

existing primary health care facilities are non-functional, the real situation appears to be

worse. Further, there is lack of data on functionality of over one thousand primary care

facilities built under the Constituency Development Fund.

The recent policy to offer free maternity services at all public health facilities is a step in

the right direction to improve access to skilled care at child birth, which is known to reduce

20

maternal deaths and thereby achievement of MDG4. However, the Service Readiness

Assessment Survey4 suggests wide variation in proportion of health facilities offering

basic emergency obstetric care across counties. Basic emergency obstetric care is much

easier to offer compared to comprehensive emergency obstetric care which requires

specialists, equipment, blood storage and an operation theatre.

The recent public expenditure tracking has shown that Kenyan health providers have much

better knowledge compared to several other countries in the region .Nearly 80% of health

staff could correctly diagnose five common health conditions and are aware how to

manage them. But, such knowledge is not optimally getting translated into service delivery

as only 40% of them were actually offering full treatment. Similarly about a third of health

staff are absent on a day of unannounced visit and over 80% of such absences were

authorized. However, there was no clear reason for nearly half of the staff on authorized

absence. Survey has shown that nearly two thirds of facilities had essential drugs and

supply was marginally better among facilities under pull system, generally facilities had

better availability of essential medicines for childcare compared to maternal care.

However, the pull system seemed to have helped to improve the supply of drugs for

maternal care.

A recent assessment of technical efficiency of health facilities suggests that generally

public primary health centers are more efficient in service delivery, but less than half of the

dispensaries need to improve their services.

2.4 Effect of Devolution on Health Care Work Force

The delivery of public health interventions requires skilled and adequately supported

health personnel. The term Human Resources for Health (HRH), according to the World

Health Organization (WHO), refers to all people engaged in actions whose primary intent

is to enhance health. These people include care givers (doctors, nurses, clinical officers,

pharmacists, etc.) to laboratory technicians, managerial personnel and other staff (cleaners,

medical records officers, health economists) who do not deliver any services to patients

directly but are vital to health system functioning. The importance of HRH is based on the

fact that delivering health services is what health workers do, supported by evidence of a

strong correlation between the density and quality of HRH in a country and population

health outcomes. HRH is one of the core building blocks of a health system and has two

21

essential components; Human Resources Development (HRD) and Human Resources

Management (HRM). These two components manage the life of a health worker from

training to employment and exit from the health workforce. How well these two

components are managed determines whether a country has numerically adequate and

motivated HRH.

Like most countries in Africa, the shortage of healthcare workers is not unique to Kenya.

Indeed, Kenya is one of the countries identified by the WHO as having a “critical

shortage” of healthcare workers. The WHO has set a minimum threshold of 23 doctors,

nurses and midwives per population of 10 000 as necessary for the delivery of essential

child and maternal health services. Kenya’s most recent ratio stands at 13 per 10 000.This

shortage is markedly worse in the rural areas where, as noted in a recent study by

Transparency International, under-staffing levels of between 50 and 80 percent were

documented at provincial and rural health facilities (KPMG,2013).

According to Scheffler, Bruckner &Spetz (2012) assessing the health labor market requires

to study both the demand and the supply sides, and how to match them in order to

determine shortages (or surpluses) of health workers. The supply of health workers

includes the number of qualified health workers willing to work at a given wage rate in the

health care sector (physicians, nurses and other care providers). Thus, training is a key

determinant of this part of the labour market. The number of trained health workers

depends on that of training institutions, the number of years of training, the education

level, the cost of training, the individual interest in working in that field, the expected

probability of getting a job after training, etc. It is linked to the market for training health

workers.

The demand for health workers, which is linked to the demand for health care, is measured

by the hiring of human resources for health by public and private institutions. Each of

these institutions competes, with varying wage rates, budgets, provider payment practices,

labour regulations and rules that determine hiring and wage decisions.

In general, the higher the wage, the larger the number of available health workers willing

to work for the health sector. Additional considerations, including better working

conditions, safety and career opportunities, also determine the decision to work in that

sector or rather to work in another sector or to migrate. The interaction between the supply

22

and demand for health workers determines the wages and other compensation, the number

of health workers employed, the number of hours they work, the geographical location and

their employment settings(Scheffler, Bruckner&Spetz, 2012).

2.4.1 Challenges in Human Resources for Health

The Kenya Health Policy 2012 – 2030, which is anchored on the Constitution, shows the

Government’s commitment to ensuring that citizens attain the highest possible standards of

health by supporting provision of equitable, affordable and quality health and related

services at the highest attainable standards to all Kenyans. The policy guides both County

and National Governments on the operational priorities they need to focus on in Health.

The country’s health sector still faces significant human resource shortages, in spite of the

investments the government has made over the years since independent and following the

devolution of health services (MoH, 2015). The situation is attributed to the increase in

population growth rate which has continued to put pressure on demand for health care

augmented by the freeze in recruitment of health personnel over time. The Ministry of

Health notes that human resource investments need to be designed to address the

availability of appropriate and equitably distributed health workers, attraction and retention

of required health workers, improving of institutional and health worker performance, and

finally training capacity building and development of the health workforce (MoH, 2015).

reports show that more than 5,000 Kenyan trained doctors have emigrated for reasons

attributable to poor pay and 3,000 more have left health to join others sectors, leaving

3,440 doctors for the nearly 46 million Kenyans who undoubtedly depend on national and

county hospitals (Kenya Health Labor Market Assessment Report of 2015). According to

Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPP&DU), the report did

not however capture the fact that majority of these doctors had either emigrated or left the

health sector after 2013, following the devolution of health services to the county

government. Many have cited negative effects of devolution including lack of schemes of

service at county level that continued to negatively impact on human resources’ practices

such as recruitment and retention, promotion, delayed salaries, lack of harmonization of

salaries, lack of opportunities for continuous medical education, among others. Measured

against the World Health Organization’s staffing norms and standards, Kenya has a

shortage of 83,000 doctors (Okech & Lelegwe, 2016).

23

2.4.2 Shifting Tasks to Lay Healthcare Workers in Primary Care

Task-shifting, already important in a continent with severe shortages of trained medical

personnel, is likely to be the only way to provide a quality, basic level of care to entire

populations. “We need to better leverage health workers,” DrDarkoh explains. “We don’t

necessarily need doctors and nurses to provide basic things like health education. We can

use so many other types of people with very little training and at little expense to build the

model of individual family and community ownership of health.”

Even non-professional people can be trained to provide education, support treatment for

HIV, deliver prescribed medicines, and use a weighing scale or glucose-testing device, say

DrDarkoh and others, freeing up specialized medical staff to perform more complicated

procedures and reducing the pressure on overstretched public-sector hospitals. One

example of such an initiative is Ethiopia’s health extension programme (HEP), which

trained extension workers to provide basic health information and education in rural areas

where none existed before.

“We recognize that communities themselves must own and lead the effort,” explains

TedrosAdhanom Ghebreyesus, minister of health for Ethiopia. Indeed, programmes such

as Ethiopia’s are particularly good at creating a cadre of health workers who do not have

advanced medical skills, but who, as local people already committed to their communities,

are also less likely to be poached by foreign healthcare systems. (The Economist

Intelligence Unit Limited [TEIUL], 2012) {The future of healthcare in Africa}

Other countries are looking at more regional solutions. In South Sudan, where human

resource shortages are at crisis levels, support from the Intergovernmental Authority for

Development (IGAD) allows neighboring countries to provide specialist labour to the

country. The originating countries continue to pay the workers’ salaries, and the South

Sudan government provides an allowance, according to DiaTimmermans, a senior health

adviser with the Joint Donor Office of the World Bank, based in South Sudan (TEIUL,

2012). Someof these challenges are currently being addressed through the proposed

staffing norms, private public initiatives such as “Beyond Zero” tolerance, managed

equipment scheme, construction of teaching referral hospitals in most of the counties.

Also, hard to reach counties are committed towards investing in human resources for

health while at the same time attract and retain them in services and have initiated various

24

incentives to attract and retain health workers such as performance best financing, risk

allowance, provision of air ticket and bonuses, among others. Planning and development of

human resources for health must be immediate action by the Ministry beyond the political

poetry of equipping county hospitals that doctors seem to have long deserted (Okech &

Lelegwe, 2016).

2.5 Chapter Summary

This chapter examined the impact of devolution on health infrastructure, access, health

care workforce, the theories and practical applications for health facilities. Several

examples were used to demonstrate the effects of devolution to health infrastructure,

workforce and access to primary health care. The next chapter will analyze the

methodology and design.

25

CHAPTER THREE

3.0 RESEARCH DESIGN AND METHODOLOGY

3.1 Introduction

This chapter outlines the overall research methodology that was used to carry out the

study. This includes the research design, population and sample size, data collection

methods, research procedures, data analysis and presentation.

3.2 Research Design

Research design provides the glue that holds the research project (Brown, Askew, Baker,

Denvir &Millet, 2003). A design is used to structure the research, to show how of the

major parts of the project-the sample or groups, measures, treatments or programs, and

methods of assignments-work together to try and address the central research questions.to

undertake the study, a descriptive research design will be used. This is a scientific study

done to a phenomenon or an object (Brown et al., 2003). This kind of study involves a

rigorous research planning and execution and includes answering research questions. This

method is preferred as it permits gathering of data from respondents in natural settings.in

this case, it’s possible for the researcher to administer the data collections tools to the

respondents in their work stations.

On the other hand, a case study focuses on a few branches selected from the total

population of other branches in the same industry (Cooper &Schindler,2000). a case study

involves intensive study of a relative small number of situations. The method was chosen

because it provides in-depth analysis of the research problem while providing valuable

insights for problem solving, evaluating and strategy.it therefore enables the researcher to

be more focused and provide analysis and recommendations that are specific and relevant.

A descriptive research design was employed in this study with an aim of securing a

representative sample of the relevant population to ensure the assessments of the target

population that would represent the general population. The research design was

appropriate for this study as it allowed for the analysis of the views of health care

personnel involved in health care. The sampling frame consisted of planning personnel

drawn from the Ministry of Medical Services and the Ministry of Public Health and

26

Sanitation. Multi-stage sampling technique was adopted in the study to identify the sample

elements. A self-administered structured questionnaire that contained both open-ended and

closed ended questions was used in collecting primary data. Additional data was collected

from theKenya health strategic plans, MTEFand Kenya Vision 2030. Others were relevant

journals, published authoritative sources from WHO and World Bank. Data collected was

cleaned, validated, coded for it to fit the statistical package. Finally, the analysis was

conducted using Statistical Package for Social Sciences (SPSS) and presented in form of

frequency tables, charts and graphs.

3.3 Population and Sampling Design

3.3.1 Population

Population defines the whole set of objects or events under investigation about which one

wishes to make inferences (Cooper & Schindler, 2003). Alarge set of observations is

referred to as a population while the smaller set is called the sample. In cases where the

population is very large a sample is often examined to make conclusions about the

population. The population of the study will be all 169 health hospitals in Nairobi County.

Stratified sampling will be used to select respondents based on cadres in order to have a

sample population that is representative. This will include Pharmacists, clinicians, Nurses,

medical officers, procurement officers and Hospital Managers.

3.3.2 Sampling Design and Sample Size

3.3.2.1 Sampling frame

A sampling frame is the list of the whole population under scrutiny from which a sample is

prepared (Cooper & Schindler, 2003).This is what is thought of as the list of all elements

in the population of interest. The sampling frame operationally targets the population from

which the sample is drawn and to which the sample data will be generalized. The sampling

frame for this study will be selected health facilities (dispensaries) and satellite clinics.

3.3.2.2 Sampling technique

To achieve a good representation of the sample and to increase reliability as well as

validity of the study as described by Saunder,Lewis& Thornhill (2012),the study used

stratified and cluster sampling to select health facility and respondents. This is where the

chance of each case being selected is not known. When the set of all possible items in a

population is very large it may be costly or time consuming to do a comprehensive analysis

27

of all the items. Therefore, evaluating characteristics of the entire population through a

representative sample will be more efficient while still proving the required information.

3.3.2.3 Sample size

A sample size is the section of part that represents the whole (Saunderset al., 2012). It is

the use of appropriate sampling techniques and with an adequate response rate is necessary

for a representative sample. Therefore, the sample size must be evaluated and all things

being equal, the greater the sampling size, the better to ensure there is more accuracy in the

results of the data taken. The sample size included a total 169 respondents selected

hospitals from selected county health facilities(Appendix 3).The strata used is as shown in

Table 2

Table 4: Nairobi County Health Facilities

Constituency Total Strata

Kamukunji 7 17

Starehe 9 18

Kasarani 13 22

Westlands 27 58

Embakasi 7 14

Njiru 4 8

Makadara 14 32

Total 81 169

3.4 Data Collection Methods

Data collection means gathering information to address those critical evaluation questions

that have been identified earlier in the evaluation process. The most important issue in data

collection is selecting the most appropriate information or evidence to answer the

questions formulated. The primary data collection method for this research was through

closed-ended questionnaire. The instrument allowed each person to respond to the same set

in a predetermined order. The questionnaire was developed by the researcher and

structured according to the research questions of the study. The instrument was physically

delivered to each health facility and respondents allowed reasonable time to complete.

Follow-ups were made through designated contact persons in the respective health

facilities. Both primary and secondary data were collected regarding health infrastructure

28

and personnel.

In terms of secondary data, a review of relevant literature on key policy initiatives and how

they have impacted on health infrastructure and personnel was undertaken. This

information was obtained from various sources including Ministry of Health official

documents such as the Kenya National Health Sector Strategic Plan (KHSSP) III, draft

Health Policy Framework, 2012 - 2030, draft Health Care Financing Strategy, and National

government documents such as Vision 2030, Medium Term Expenditure Framework

(MTEF) paperand the Constitution. Additional data was also collected from, journal

articles, among others. This was supported by in-depth interviews with key stakeholders in

the sector at county levels.

3.5 Research Procedures

A pilot test was conducted for 30 respondents in westlands sub-county health facilities to

verify the validity of the items in the closed-ended questionnaire. Based on the responses

of the pilot test, the questions were adjusted appropriately to increase clarity and ascertain

the time required to complete. The final questionnaire was reviewed and sent out to the

respondents. A letter of introduction, stating the purpose of the study was also attached to

each questionnaire.

3.6 Data Analysis Methods

The qualitative data was systematically organized using descriptive statistics to facilitate

analysis. Qualitative analysis is the examination of non –measurable data such as the

organizations reputation management, or a respondents’ feelings about a situation.

Descriptive statistics was used to analyze, explain and summarize properties of the data

collected aided by a Statistical Package for the Social Sciences (SPSS) and Excel. The data

was presented using graphs, charts and tables.

3.7 Chapter Summary

This chapter gave insight into how the study was conducted. Specifically, it has explained

the research design, study population, methods of data collection, research procedures, data

analysis and presentations. The primary data was collected with the aid of closed-ended

questionnaire that were administered by the researcher to the respondents in selected

branches and department. The data was analyzed by employing descriptive statistics such

as percentages and frequencies aided by SPSS and Excel. Presentation was through graphs,

29

charts and tables.Chapter four provides the results and findings followed by summary of

the findings, discussion, conclusion and recommendations in chapter five.

30

CHAPTER FOUR

4.0 RESULTS AND FINDINGS

4.1 Introduction

This chapter presented the results and findings of the primary data collected from the

respondents of Nairobi county healthcare facilities. It also presents the findings based on

research questions outlined in chapter one and results analyzed in form of graphs, charts

and tables. The research used a structured closed ended questionnaire.

4.2 Response Rate and General Information

4.2.1 Response rate

The sample of the study was 169 respondents from various health facilities in Nairobi

county One hundred questionnaires were issued and ninety-four questionnaires were

returned representing 94 per cent response rate. The other health facilities were not

covered due to inaccessibility and security reasons.

4.2.2 General information

The general information section gave an understanding of the profile of the respondents.

Questions on the department, position held, level of education, gender, age and the years of

service to the facility was presented.

4.2.2.1 Department

The study sought to find out the departments which respondents serve and the results are

analyzed in the Table 4.1

31

Table 4.1: Departments interviewed

Frequency Percent

Medical 42 45

Curative 8 8

Laboratory 13 14

Social Work 3 3

Procurement 9 10

Administration 17 18

Nutrition 2 2

Total 94 100

Table 4.1 above indicates that 45% of the respondents were in the medical department, 8%

curative, laboratory 14%, 3% social work,10% procurement,18% administration and 2%

nutrition.

4.2.2.2 Designation

The questionnaire sought to know the designation and the staffing of the respondents

across a range of cadres required for delivery of the Kenya Essential Package for Health

(KEPH) in the health system. The findings are summarized in Table 4.2.

Table 4.2: Position of respondents in the organization

Frequency Percent

Clinical Officer 25 27

Medical Officer 7 8

Pharmacist 5 5

Midwife 2 2

Laboratory Technician 13 14

Accountant 11 12

Nurse 7 7

Health Information Officer 5 5

Procurement Officer 10 11

Administrator 2 2

Consultancy 1 1

ICT expert 2 2

Driver 1 1

Nutrition officer 2 2

Social worker 1 1

32

Table 4.2 above indicates that 27% of the respondents were clinical officers, 14%

represented lab technicians, 12% accountants, 5% health information officers, 2% nutrition

officers, and other positons as shown above.

4.2.2.3 Level of Education

Level of education of the respondents was asked to know the literacy levels of the

respondents they are summarized in Table 4.3

Table 4.3: The level of education of the respondents

Frequency Percent

Diploma 33 35

Bachelor’s Degree 57 61

Master’s Degree 4 4

Table 4.3 above indicates that 35% of respondents had a diploma, 61% had a Bachelor’s

degree and 4% had a Master’s degree.

4.2.2.4 Gender

The study sought to know the gender balance in the health facility. The results were

presented in Table 4.4

Table 4.4: The gender of the respondents

Frequency Percent

Male 56 60

Female 38 40

Table 4.4 above indicates that 60% percent of the respondents were male and 40% were

female.

4.2.2.5 Age of the Respondents

The age bracket of the respondents was analyzed and this is shown in Table 4.5

33

Table 4.5: The age of the respondents

Frequency Percent

20-30 years 29 31

31-40 years 45 48

41-50 years 19 20

Over 51 years 1 1

Table 4.5 indicates that 31% respondents are aged between 20 to 30 years, 48% aged

between 31 to 40 years, 20% aged between 41 to 50 years and 1% over 51 years.

4.2.2.6 Years of Service in the Organization

Years of service to the institution was analyzed to know the retention rate of staff. The

findings are shown in Table 4.6

Table 4.6: The years of service in the organization

Frequency Percent

less than 2 years 35 37

3-5 years 41 44

6-8 years 17 18

over 9 years 1 1

Table 4.6 above indicates that 37% of the respondents have worked in the organization for

less than 2 years, 44% between 3 to 5 years, 18% between 6 to 8 years and 1 % above 9

years. This correlates with the findings in table 4.5 on age of respondents which shows the

employees are middle aged.

4.2.2.7 Difference between gender and position held

The study sought to find out if there was a difference between gender and position held in

the institution using independent t-test. The results are shown in the tables below:

34

Table 4.7: Difference between gender and position held

4.7 Group Statistics

your gender N Mean

Std.

Deviation

Std.

Error

Mean

your

position

Male 56 5.0000 4.00454 .53513

Female 38 5.3421 3.08682 .50075

Table 4.7above shows that there are 56 Males and 38 Females. The mean of the positions

for the gender of males was 5, and the mean of the positions for the gender of females was

5.3.

Table 4.8: Independent samples test

Levene's Test

for Equality of

Variances t-test for Equality of Means

F Sig. t df

Sig. (2-

tailed)

Mean

Difference

Std. Error

Difference

95% Confidence

Interval of the

Difference

Lower Upper

your

position

Equal

variances

assumed

3.522 .064 -.444 92 .658 -.34211 .76991 -1.87121 1.18700

Equal

variances

not

assumed

-.467 90.427 .642 -.34211 .73288 -1.79800 1.11379

Table 4.8 shows the levenes test of equality. If P< 0.05, reject Ho and accept H1 because

the variances/means are significantly different. If P>0.05, accept Ho, this means the

variances are not significantly different. Table 4.32.2 shows that P>0.05 which was

P=0.658 so we can say the mean variances between male and females and their position in

the institution is not significant.

4.3 The Effect of devolution on health infrastructure

In this section, the study sought to establish the effect of devolution on health

infrastructure in county health facilities. The study sought to know from respondents

whether hospital infrastructure had improved since county government came into place and

whether minimum basic facilities were available for proper running of the facility.

35

4.3.1 Cleanliness

Availability of clean toilets to staff and patients was analyzed to find out the level of

cleanliness and if they were in place. The findings are summarized in Table 4.9below:

Table 4.9: Clean toilets available for staff and patients

Frequency Percent

Yes 88 94

No 6 6

Table 4.9above shows that 94% of the respondents agree that clean toilets were available

to staff and patients and 6% disagreed.

4.3.2 Availability of protected placenta pit

The study sought to establish whether protected placenta pits were available within the

facility. The findings are summarized in Table 4.10

Table 4.10: Availability of protected placenta pit

Frequency Percent

Yes 46 49

No 48 51

Table 4.10above shows that 49% of the respondents agree to have a protected placenta pit

and 51% disagreed.

4.3.3 Disposal

The questionnaire sought to find out how the facility finally disposes of sharp waste, such

as needles or blades. The results are presented in Table 4.11

Table 4.11: Disposal of sharp wastes

Frequency Percent

Burn in incinerator 36 38

Open Burning 4 4

Remove offsite stored in covered container 54 58

Table 4.11above shows that 38% of the sharp wastes are burned in incinerators, 4% open

burning and 58% are removed offsite stored in covered containers.

4.3.4 Power supply

All health facilities should have some form of power supply. The study sought to find out

36

if the facility had a generator as a back-up or stand-by. The results are summarized in

Table 4.12

Table 4.12: Availability of a generator

Frequency Percent

Yes 89 95

No 5 5

Table 4.12 above shows that 95% of the respondents agree that the facilities have a

generator and 5% disagreed.

4.3.5 Water supply

Health facilities should have sufficient and clean piped water supply for drinking, personal

hygiene and, where applicable, for food preparation as per the health infrastructure norms

and standards. The study sought to find out if this was the case. Table 4.13 presents the

findings.

Table 4.13: Water supply

Frequency Percent

Piped into facility 82 87

Public tap 9 10

Borehole 2 2

Purchase from water

vendors 1 1

Table 4.13 above shows that 87% of the respondents have access to piped water to the

facility, 10% have access to public tap, 2% have a borehole and 1% purchase water from

water vendors.

4.3.6 Communication Facilities

Health facilities should have access to communication facilities for example phones, two

way radios among others. The results are shown in Table 4.14

Table 4.14: Communication Facilities

Frequency Percent

Yes 93 99

No 1 1

37

Table 4.14 above shows that 99% of the respondents had communication facilities and 1%

didn’t have.

4.3.7 Internet Facility

Health facilities should have a form of wired or wireless connectivity for purposes of

communication and information transfer, which should be maintained in good working

order. The study sought to find if health facilities had access to internet facility and the

findings are presented in Table 4.15

Table 4.15: Email /internet facility

Frequency Percent

Yes 76 81

No 18 19

Table 4.15 above shows that 81% of the respondents had access to email /internet within

the facility and 19% of the respondents didn’t have access.

4.3.8 Medical equipment

The research sought to find out the state of medical equipment in terms of its current

condition, functionality, its relevance, newer technology and if well maintained. The

findings are shown in Figure 4.1

38

Figure 4.5: State of medical equipment

Figure 4.1 above indicates that 5% of the respondents say the state of their medical

equipment is very good, 63% say it’s good, 6% say it’s very bad, 25% say it’s bad and 1%

didn’t know.

4.3.9 New equipment

The study sought to find out if new equipment has been bought since county government

came into place. The findings are summarized in Table 4.16

Table 4.16: New equipment

Frequency Percent

Yes 60 64

No 34 36

Table 4.16 above shows that 64% of the respondents said new equipment has been bought

since county government came into place and 36% disagreed.

4.3.10 Type of equipment bought

For those who said yes, the research wanted to know which equipment has been bought

since county government came into place. The findings are shown in Graph 4.1.

5%

63%

6%

25%

1%

State of medical equipment

Very good

Good

Very bad

Bad

Don’t know

39

Graph 4.1: New equipment bought since county government came into place

Graph 4.1 above shows that 15% of respondents said computers were bought, 7%

ambulances, 4% beds, 20% lab equipment, 12% X-ray machine, 3% generators, 2%

nebulizers and 37% didn’t know.

4.3.11 Transportation

The study sought to find out what mode of transport is used during emergencies by the

facility. The results are presented in Table 4.17

Table 4.17: Transport used during emergencies

0

5

10

15

20

25

30

35

40

15

7

37

4

20

12

32

Per

cen

t (%

)

New Equipment

New equipment bought

Frequency Percent

Ambulance 90 96

40

Table 4.17 above shows that 96% of respondents use ambulance during emergencies, 1%

use taxi, 1% use motorcycle and 2% use private cars.

4.3.12 Relation between budget for the year and state of medical equipment

The study sought to find out if there was a relationship between budget for the year and

state of medical equipment using correlation analysis. Table 4.18 presents the findings

Table 4.18: Correlation between budget for the year and state of medical equipment

Budget for

the year

State of

medical

equipment

Budget for the year Pearson

Correlation

1 .158

Sig. (2-tailed) .129

N 94 94

State of medical equipment Pearson

Correlation

.158 1

Sig. (2-tailed) .129

N 94 94

Table 4.18 above shows the Pearson’s r for the correlation is 0.158 which means that as the

budget for the year increases the state of medical equipment increase. We had a weak

positive correlation between size of the catchment population and the total number of staff.

The Sig. (2-Tailed) value in our case is 0.129. This value is more than 0.05. Because of

this, we can conclude that there is no statistically significant correlation between budget

for the year and the state of medical equipment.

4.4 The Effect of Devolution on Access to Health Services

In this sub-section results are presented in terms of how devolution has improved access to

health facilities. Like in the first case it sought to know from the respondents the proximity

of health facility to the community, availability of funds to run the facility, availability of

Taxi 1 1

Motorcycle 1 1

Private cars 2 2

41

transport and how well equipped the facility is adequate funding for medicines ,medical

supplies and adequate funding for maintenance of buildings.

4.4.1 Catchment population

This is the population that the health facility serves. The study sought to find out the

catchment population to which the county health facilities serve. The results are

summarized in Figure 4.2

Figure 4.6: Catchment population

Figure 4.2 above shows that 63% of the respondents’ facility, serve between 5000 to

10,000 people, 14% serve between 0 to 5,000 people and 23% serve over 10,000 people.

4.4.2 Transport used by patients

The study sought to find out what mode of transport is used by patients who are referred

from other facilities to the health facility during emergencies. The results are shown in

Table 4.19

Table 4.19: Transport used by patients referred from other facilities

Frequency Percent

Public bus 50 53

Private car 5 6

14%

63%

23%

Catchment population

0-5000 people

5000-10000 people

Over 10000 people

42

Ambulance 32 34

Motorcycle 3 3

People carry/push or pull

patient 2 2

Never receive referrals 1 1

Don’t know 1 1

Table 4.19 above shows that 53% of the respondents said that patients referred from other

facilities use public cars/bus,6% use private cars,34% use ambulance,3% use

motorcycle,2% people carry,1% never receive referrals and 1% don’t know.

4.4.3 Timeliness

The study sought to know how much time it takes for the patients to reach the healthcare

facilities. The results are summarized in Figure 4.3

Figure 4.7: How much time it takes patients to get to facility

Figure 4.3 above shows that 11% of the respondents said that patients take about 30

minutes to get to the facility,8% use 1 hour,3% use over 1 hour and 78% don’t know how

much time patients take.

4.4.4 Relationship between catchment area and time taken to get to facility

The study sought to find out if there was a relationship between catchment area and time

11%

8%

3%

78%

How much time it takes patients to get to facility

30 Mins

1 hour

Over 1 hour

Dont know

43

taken by patients to get to facility using correlation analysis. The findings are shown in

Table 4.20:

Table 4.20: Correlation between catchment area and time taken to get to facility

Correlations

size of the

catchment

population

How much

time it takes

patients to

get to

facility

size of the catchment population Pearson Correlation 1 .132

Sig. (2-tailed) .205

N 94 94

How much time it takes patients to get

to facility

Pearson Correlation .132 1

Sig. (2-tailed) .205

N 94 94

Table 4.20 shows the Pearson’s r for the correlation is 0.132 which means that there is a

weak relationship between catchment area and time it takes for patients to get to the

facility. This means that change in catchment area is not correlated with changes in the

time taken to get to facility. Also, Pearson’s r is positive which means that as the

catchment area increases in value, the time taken to get to facility also increase in value

and vice versa. Similarly, as one variable decreases in value, the second variable also

decreases in value.

The Sig. (2-Tailed) value in our case is 0.205. This value is greater than .05. Because of

this, we can conclude that there is no statistically significant correlation between catchment

area and time taken by patients to get to facility.

4.4.5 Funding

What is the source of funding for the facility. The results are presented in Figure 4.4

44

Figure 4.4: Source of funding

Figure 4.4 above shows that 6% of respondents are funded by donors, 53%

bymainstream government and 41% by local government.

4.4.6 Budget for the year

The study sought to find out what the budget for the year was. The findings are

presented in Figure 4.5

41%

53%

6%

Source of funding

Government

Local Government

Donors

45

Figure 4.5: Budget for the year

Figure 4.5 above indicates that 59% of the respondents’ budget for the year was between

1,000,001 to 7, 000, 000, 40% between 500,001 to 1,000,000 and 1% between 250,000 to

500,000.

4.4.7 Relation between source of funds and budget

The study sought to find out if there was a relationship between source of funding and the

budget the facility received for the year using correlation analysis. Table 4.21 presents the

findings

Table 4.21: Correlation between source of funds and budget

Source of

funding

Budget for the

year

Source of funding Pearson Correlation 1 -.265**

Sig. (2-tailed) .010

N 94 94

Budget for the year Pearson Correlation -.265** 1

Sig. (2-tailed) .010

N 94 94

**. Correlation is significant at the 0.01 level (2-tailed).

Table 4.21 above shows the Pearson’s r for the correlation is -0.265 which means that as

source of funding increases in value, the budget for the year decreases in value. We had a

weak negative correlation between source of funding and the budget.

1%

40%

59%

Budget for the year

250,000-500,000

500,001-1,000,000

1,000,001-7,000,000

46

The Sig. (2-Tailed) value in our case is 0.001. This value is less than 0.05. Because of this,

we can conclude that there is a statistically significant correlation between source of

funding and budget for the year.

4.4.8 Adequate Funding

The study sought to know if adequate funding is allocated for purchase of medicines,

equipment and maintaining buildings. The results are presented in Table 4.22

Table 4.22: Adequate funding allocated for medicine

Frequency Percent

Yes 16 17

No 78 83

Table 4.22above shows that 17% of the respondents agree that there is adequate funding

for medicine and 83% disagreed.

Table 4.22: Adequate funding allocated for equipment

Frequency Percent

Yes 21 22

No 73 78

Table 4.22 above shows that 22% of the respondents agree that there is adequate funding

for equipment for the facility and 78% disagreed.

Table 4.23: Adequate funding allocated for maintaining buildings

Frequency Percent

Yes 12 13

No 82 87

Table 4.23 above shows that 13% of the respondents agree that there is adequate funding

for maintaining buildings and 87% disagreed.

4.4.9 Unit for repair and maintenance

The research sought to know if there was a designated unit for repair and maintenance of

equipment which have to be in good working condition for effective running of the

hospital. The results are shown in Table 4.24

47

Table 4.24: Designated unit for repair and maintenance of equipment

Table 4.24 above shows that 36% of the respondents had a designated unit for repair and

maintenance of equipment and 64% didn’t have.

4.4.10 Unit for repair and maintenance predicts the state of medical equipment

The study sought to find out if availability of a unit for repair and maintenance predicts the

state of medical equipment using simple linear regression model. The results are shown in

Tables 4.25.1, Table 4.25.2, Table 4.25.3

Table 4.25: Unit for repair and maintenance predicts the state of medical equipment

4.25.1 Model Summary

Model R R Square Adjusted R Square

Std. Error of

the Estimate

1 .327a .107 .097 .91046

a. Predictors: (Constant), Do you have a designated unit for repair and

maintenance of equipment

Table 4.25.1 shows the R value is 0.327 which is the simple correlation and indicates a

weak degree of correlation. The R2 value is 10.7% which indicates how much of the total

variation in the dependent variable, state of medical equipment, can be explained by the

independent variable, availability of a repair and maintenance unit. In this case, 10.7% is

very low.

4.25.2 ANOVAa

Model

Sum of

Squares df

Mean

Square F Sig.

1 Regression 9.142 1 9.142 11.028 .001b

Residual 76.263 92 .829

Total 85.404 93

a. Dependent Variable: State of medical equipment

b. Predictors: (Constant), Do you have a designated unit for repair and

maintenance of equipment

Table 4.25.2 shows p< 0.001 which is less than 0.05, and indicates that, overall, the

regression model statistically significantly predicts the outcome variable (i.e., it is a good

Frequency Percent

Yes 34 36

No 60 64

48

fit for the data).

4.25.3 Coefficientsa

Model

Unstandardized

Coefficients

Standardized

Coefficients

t Sig. B

Std.

Error Beta

1 (Constant) 1.469 .334 4.401 .000

Do you have a

designated unit

for repair and

maintenance of

equipment

.649 .195 .327 3.321 .001

a. Dependent Variable: State of medical equipment

From table 4.25.3 we can state the regression equation as:

Unit for repair and maintenance=1.469+0.649 (state of medical equipment)

4.4.11 Basic emergency obstetric care

The research sought to know if the health facility offered basic emergency obstetric care

that is care during pregnancy, child birth and the postpartum period. The results are

presented in Table 4.26

Table 4.26:Offer basic emergency obstetric care

Frequency Percent

Yes 87 93

No 7 7

Table 4.26 above indicate that 93% of the respondents agree to offering basic emergency

obstetric care and 7% disagreed.

4.4.12 Emergency obstetric care that require specialists

The study sought to find out what happens to comprehensive emergency obstetric care that

require specialists as county health facilities don’t have specialists. The results are shown

in Table 4.27

Table 4.27: Emergency obstetric care that require specialists

Frequency Percent

Don’t

know 24 26

49

Referrals 70 74

Table 4.27 above indicates that 74% of the respondents said during comprehensive

emergency obstetric care that require specialists’ patients are referred to higher level

facilities and 26% didn’t know what happens to such cases.

4.4.13 Free maternity services

The study sought to find out if the county health facilities offered free maternity services.

The findings are presented in Table 4.28

Table 4.28: Free maternity services

Frequency Percent

Yes 87 93

No 7 7

Table 4.28 above indicates that 93% of the respondents offered free maternity services and

7% disagreed.

4.4.14 Labour ward

All primary health care facilities are required to have a labour ward. The study sought to

find out if this was the case. The results are summarized in Table 4.29.

Table 4.29:Labour ward

Frequency Percent

Yes 65 69

No 29 31

Table 4.29 above indicates that 69% of the respondents had a labour ward and 31% did not

have.

4.4.15 Inpatient care

The study sought to find out if the facility provided inpatient care. Table 4.30 presents the

findings

Table 4.30: Offer routinely inpatient care

Frequency Percent

Yes 32 34

50

No 62 66

Table 4.30 above indicates that 34% of the respondents routinely offered inpatient care and

66% disagreed.

4.4.16 Beds

The study sought to find if the facility had beds for overnight observations. Table 4.31

presents the findings:

Table 4.31: Have beds for overnight observation

Frequency Percent

Yes 39 42

No 55 58

Table 4.31above indicates that 42% of the respondents had beds for overnight observation

and 5% disagreed.

4.4.17 Number of inpatient beds

The study sought to find out how many inpatient beds the facility had. The results are

shown in Graph 4.2

51

Graph 4.2: Number of inpatient beds

Graph 4.2 above indicates that 68% of the respondents didn’t have inpatient beds, 6% had

two beds, 4% had 10 beds, 5% had 20 beds, 2% had 50beds and 1% had 4 beds.

4.4.18 Condition of laboratory

The study wanted to find out the condition of the laboratory. The findings are shown in

Figure 4.6

0

10

20

30

40

50

60

7068

61 1 2 1

41 1 3 5

1 2 2

Per

cen

t

Number of beds

How many inpatient beds

52

Figure 4.6: Condition of laboratory

Figure 4.6 above shows that 7% of respondents said that their laboratory is in very good

condition, 78% say it’s good, 1% say it’s very bad and 14% say it is bad.

4.4.19 Replenishment of medical supplies

The study sought to find out how often medical supplies was replenished. The findings are

shown in Figure 4.7

Figure 4.7: Replenishment of medical supplies

Figure 4.7 above shows that 5% of the respondents had monthly replenishment of medical

supplies, 34% quarterly, 52% half yearly and 9% yearly.

7%

78%

1% 14%

Condition of Laboratory

Very

good

Good

5%

34%

52%

9%

Replenishment of medical supplies

Monthly

Quarterly

Half yearly

Yearly

53

4.4.20 Frequency of store audit

The study sought to find out how frequent the health facility store was audited. The results

are presented in Figure 4.8

Figure 4.8: Store audit

Figure 4.8 above shows that 9% of the respondents had their stores audited monthly, 22%

quarterly, 65% half yearly and 4% yearly.

4.5 The Effect of Devolution on Health Care Workforce

This section tried to analyze how devolution has improved healthcare workforce. Like in

the previous two cases it sought to know from the respondents the number of staff, if they

receive any medical education, mechanisms used to motivate them, if they receive any job

promotion and things related to the work environment they would want improved.

4.5.1 Number of staff

The study sought to find out the total number of staff the facility had. The findings are

shown in Table 4.32

Table 4.32: Number of staff

Frequency Percent

9%

22%

65%

4%

How often is store audited

Monthly

Quarterly

Half Yearly

Yearly

54

1-5 staff 3 3

5-10staff 11 12

10-15staff 72 77

More than

15 8 8

Table 4.32 above indicate that 3% of the respondents had between 1 to 5 staff ,12%

between 5 to 10 staff ,77% between 10 to 15 staff and 8% more than 15 staff.

4.5.2 Adequately staffed

We sought to find out if in the respondents’ opinion they were adequately staffed. The

findings are shown in Table 4.33

Table 4.33: Adequately staffed

Frequency Percent

Yes 5 5

No 89 95

Table 4.33 above indicates that 5% of the respondents said they were adequately staffed

and 95% disagreed.

4.5.3 Medical education

The research sought to know if the facility offered continual medical education to their

staff, and if they did, the type of education as shown in Table 4.34 and Graph 4.3

Table 4.34: Continual medical education

Frequency Percent

Yes 47 50

No 47 50

Table 4.34 above indicates that 50% of the respondents agreed that they receive continual

medical education and 50% disagreed.

55

Graph 4.3: Medical education received

Graph 4.3 above shows that 50% of the respondents didn’t receive any continual medical

education, 10% received training on first aid, 7% on first aid, 3% on obstetric emergencies

and 2 % on diarrhea among others.

4.5.4 Appraisal

The study sought to find out if the facility did any appraisal as a performance monitoring

tool. Table 4.35 presents its findings:

Table 4.35: Existence of appraisal

Frequency Percent

Yes 88 94

No 6 6

Table 4.35 indicates that 94% of the respondents did appraisals and 6% did not do

appraisals.

4.5.5 Frequency of appraisals

The research sought to find out the frequency of appraisals done. The findings are shown

in Figure 4.9:

05

101520253035404550

50

1310 7 9

4 3 2 2

Per

cen

t

Type of education

Type of medical education received

56

Figure 4.9: Frequency of Appraisals

Figure 4.9 above shows 20% of respondents do quarterly appraisals, 55% half yearly, 19%

yearly and 6% don’t do appraisals.

4.5.6 Motivation

The study sought to find out if there were any mechanisms used to motivate staff. Table

4.36 presents the findings:

Table 4.36: Mechanisms used for staff motivation

Frequency Percent

Tea for staff 11 12

Lunch for staff 6 7

Awards 13 14

Letters of appreciation 6 6

Time-off 3 3

No mechanisms for staff

motivation 54 57

Trainings 1 1

Table 4.36 above indicates that 12% of the respondents were offered tea as a motivator,

7% lunch,14% awards,6% letter of appreciation,3% got time-off,57% no mechanisms used

and 1% through training.

20%

55%

19%

6%

How often are appraisals done

Quarterly

Half yearly

Yearly

Others

57

4.5.7 Promotion

The research wanted to find out if employees received promotions for good performance or

any form of formal recognition. Table 4.37 presents the findings:

Table 4.37: Receive promotion

Frequency Percent

Yes 89 95

No 5 5

Table 4.37 above indicates that 95% of the respondents received promotion for an

employee’s good performance and 5% disagreed.

4.5.8 Criteria for promotion

The study sought to find out the criteria used when promoting staff. Table 4.38 presents the

findings:

Table 4.38: Criteria for promotion

Frequency Percent

Appraisals 42 45

Academic qualifications 51 54

Others 1 1

Table 4.38 above indicates that 45% of the respondents received promotion based on

appraisals done,54% academic qualifications and 1% others not specified.

4.5.9 Things to be improved

The study sought to find out if there are things related to the working situation that the staff

would like to see improved and would enhance their ability to provide good quality of care

services. The results are summarized in Graph 4.4

58

Graph 4.4: Areas of Improvement

Graph 4.4 above shows that 54% of the respondents would love to be trained to improve

their ability to provide quality care services,7% more knowledge,3% more support from

supervisors,16% more supplies,5% better quality equipment,5% emotional support to staff

among others.

4.5.10 Relation between catchment area and number of staff

The study sought to find out if there was a relationship between catchment area and the

number of staff using correlation analysis. Table 4.39 presents the findings

Table 4.39: Correlation between size of the catchment population and total number of

staff

Total number of staff

size of the

catchment

population

0

10

20

30

40

50

60 54

73

16

5 6 4 5

Per

cen

t

Thing to be improved

Things that need to be improved

59

Total number

of staff

Pearson

Correlation

1 .276**

Sig. (2-

tailed)

.007

N 94 94

size of the

catchment

population

Pearson

Correlation

.276** 1

Sig. (2-

tailed)

.007

N 94 94

**. Correlation is significant at the 0.01 level (2-tailed).

Table 4.39 above shows the Pearson’s r for the correlation is 0.276 which means that as the

size of the catchment population increases the total number of staff increase in value. We

had a weak positive correlation between size of the catchment population and the total

number of staff.

The Sig. (2-Tailed) value in our case is 0.007. This value is less than 0.05. Because of this,

we can conclude that there is a statistically significant correlation between size of the

catchment population and the total number of staff.

4.1 Chapter summary

The chapter highlighted the findings of the study which was to assess the impact of

devolution on health care systems using the case of Nairobi county health facilities. The

results were based on research questions from where a questionnaire was prepared and

administered to respondents. The data collected was analyzed and findings presented in

descriptive statistics in form of pie charts, graphs and tables. Chapter five presents the

discussions, conclusions and recommendations.

60

CHAPTER FIVE

5.0 SUMMARY, DISCUSSIONS, CONCLUSIONS AND RECOMMENDATIONS

5.1 Introduction

This section presents a summary and discussions of the major findings. The chapter also

draws conclusions, makes recommendations for improvement, and finally provides areas

where further studies can be conducted.

5.2 Summary of findings

The purpose of this study was to assess the impact of devolution on healthcare systems

with a focus on Nairobi county health facilities. The study was guided by three research

questions namely; what is the effect of devolution on health infrastructure? what is the

effect of devolution on access to health services? what is the effect of devolution on health

care workforce? The research targeted a population of ninety-four employees working in

various departments in county health facilities and used a stratified sampling technique.

Primary and secondary sources of data were used in this study where primary sources of

data were collected by use of closed ended questionnaire after a pilot test had been

conducted. The collected data was analyzed using SPSS to compute both descriptive and

inferential statistics including frequencies, charts, t-tests, regression and correlation. The

results were thereafter presented in form of tables, graphs and charts.

The study revealed that majority of the respondents agreed that hospital infrastructure had

improved with devolution. Most facilities had piped water to the facilities, availability of

communication facilities, had power/electricity and backup generators. It was also

observed that medical equipment was in good condition in most facilities in terms of its

functionality and new equipment had been acquired under the medical equipment scheme

such as x-ray machines, nebulizers, lab equipment among others.

The findings on access to healthcare services revealed that majority of respondents agreed

that adequate funding is not allocated for purchase of medicines, purchase of equipment

and maintenance of buildings and ambulances was the most common means of transport

used by health facilities during emergencies. The findings on healthcare workforce

revealed that majority of the respondents agreed that they were inadequately staffed. Also

most of the respondents agreed that more training would mostly improve their ability to

61

provide quality care services. Of importance to note, was the lack of motivation

mechanisms by majority of the healthcare facilities that led to low morale of staff thus

under productivity.

5.3 Discussion

The findings from the study are discussed here according to research questions. It entails

interpretations of the results or major findings by comparing them with the theoretical

background presented in the literature review.

5.3.1 The Effect of Devolution on Hospital Infrastructure

The findings revealed that most of the respondents agreed to a great extent that they have

communication facilities. Also, a large proportion of the respondents suggested that to a

great extent internet facilities are available. Health infrastructure relates to all the physical

infrastructure, non-medical equipment, transport, and technology infrastructure (including

ICT) required for effective delivery of services (KHP, 2014).

The findings revealed that most of the respondents agreed to a great extent that the state of

their medical equipment was good and most of the respondents agreed to new equipment

being bought. Some of Kenya’s health facilities lack adequate premises for priority

interventions, such as delivery rooms, maternity, laboratories, theatres (GoK, 2005). The

findings revealed that most of the respondents agreed to a great extent that they had labour

wards and good state of laboratories. Physical infrastructure is one of the most important

facilities to a health facility for it to provide quality care. Most of medical equipment used

in public health facilities is more than 20 years old (some double their lifespan) and

characterized by frequent breakdowns. Furthermore, most public facilities do not have

modern equipment such as dialysis machines, radiology equipment, laundry machines and

theatre equipment. The available equipment falls far short of the required numbers, of

those available, about 50% of the equipment is too old to pass required standards and that

maintenance of equipment has been inadequate (MoH, 2015).

The findings also revealed that most of the respondents agreed to have piped water to the

facility Similarly, MoH (2017) points out that all health facilities should have sufficient

and clean piped water supply which complies with all relevant laws and which is available

at all times for drinking, personal hygiene and, where applicable, for food preparation.

Sufficient water collection points and water use facilities must be available at all Health

62

facilities to allow convenient access.

On the other hand, most of the respondents didn’t have protected placenta pits. This

contradicts (MoH,2017) that states all primary health facilities should have at least one

protected placenta pit. Similarly MoH (2016) observed that most dispensaries lack placenta

pits and septic tanks for the safe disposal of maternity health care wastes. Keeping the

health infrastructure and the equipment in good condition would undoubtedly change the

public’s perception of good quality care and this in turn would encourage people to use the

available health services (GoK, 2005). Health infrastructure is key in restoring public

perception of good quality care and achieving devolution goals on improvement of primary

health care facilities.

5.3.2 Effects of Devolution on Access to Health Services

Access implies physical distance, financial outlays and socio-cultural factors. Improving

access – geographically, financially and socioculturally – is expected to increase the

utilization of health care services, as the services become closer and cheaper for the client

(GoK, 2005). The findings revealed that most of the respondents had inadequate funding

for medicines, equipment and maintenance of buildings. The observations made by the

(MOH: NHA 2009/10) stated that the small share of the health sector in the Government

budget (in 2009/10 only 4.6%) points to a general underfinancing of publicly provided

services which is in agreement with the findings.

The findings have shown change with devolution where most respondents agreed that there

was availability of ambulances during emergencies and comprehensive cases that require

specialists had referrals done.KHSSP (2017) stated that, poor public transport, weak

referral systems, insufficient community health services and weak collaborations with

other service providers have perpetuated poor geographical access to health services. The

findings revealed that most of the respondents agreed to have offered free maternity

services to their patients. As observed by the Service Readiness Assessment Survey4,the

recent policy to offer free maternity services at all public health facilities is a step in the

right direction to improve access to skilled care at child birth, which is known to reduce

maternal deaths and thereby achievement of MDG4.

The findings revealed that most respondents served an average population of between 5000

to 10,000 people, which shows a low reach out to the intended population. This is contrary

63

to KEPH (2013) that states that a health centre should serve an average population of

30,000 people. GoK (2005) states that, access is a measure of the ability of a

person/community to receive available services. It is a pre- requisite to high utilization of

health services as it brings services closer to the people as well as makes them cheaper.

5.3.3 Effects of Devolution on Health Care Workforce

The findings revealed that most of the respondents suggested that to a great extent they are

inadequately staffed. This is in agreement with the MOH observation that states, the

country’s health sector still faces significant human resource shortages, in spite of the

investments the government has made over the years since independent and following the

devolution of health services (MoH, 2015).

Shortage of healthcare workers affects functionality of health institutions. The findings

revealed that most of the respondents had between 10-15 staff. As stated by the WHO that

set a minimum threshold of 23 doctors, nurses and midwives per population of 10 000 as

necessary for the delivery of essential child and maternal health services (KPMG, 2013).

The findings also revealed that most of the respondents agreed that training would be one

of the things they would love to see, that would improve their staff ability to provide good

quality care of services. MoH,(2015) notes that human resource investments need to be

designed to address the availability of appropriate and equitably distributed health workers,

attraction and retention of required health workers, improving of institutional and health

worker performance, and finally training capacity building and development of the health

workforce.

The findings also revealed that majority of the respondents had no mechanisms put in

place for staff motivation. As stated by the Kenya HRH Strategic Plan and from the

Ministry of Health’s signed commitments at the Human Resources for Health Conference

in Brazil in 2013, under commitment 4, there needs to be increased spending in the Health

Sector on HRH beyond staff salary and allowances by 2017. Allocate HRH budgets

beyond employee’s emoluments towards employee welfare, employee relations, reward

and recognition, work climate improvement, occupation health and safety by 2017.

5.4 Conclusion

The following conclusions were drawn from the research findings based on the research

64

question which was to analyze the impact of devolution on health care systems using the of

Nairobi county health facilities.

5.4.1 The Effect of Devolution on Health Infrastructure

Availability of good health facility infrastructure would undoubtedly change the public’s

perception of good quality care. Communication facilities was one of the most improved

hospital infrastructure. The state of medical equipment was good and new equipment had

been bought with devolution of health services. Also to note was the availability of labor

wards, laboratories were in good condition, although placenta pits were the least available

in the health facilities. This means that there was considerable improvement on health

infrastructure with devolution.

5.4.2 The Effect of Devolution on Access to Health Services

Access to health services significantly affect utilization of health care services. With

devolution, ambulances were available for emergency services, free maternity was

available which implies skilled care available at child birth thus a reduction on maternal

deaths. Inadequate funding was allocated to medicine, equipment and maintenance of

buildings which implies underfunding and, the catchment area that the county health

facilities served was low and needs to be improved.

5.4.3 The Effects of devolution on health care workforce

Health workers are a backbone to health facilities. A shortage of health workers in the

facilities implies that strain is put on the available staff that in turn affects their service

delivery. Devolution has not addressed this challenge yet. No mechanisms were put in

place to motivate staff ,only a few health facilities, implying that Nairobi county healthcare

workforce is majorly demotivated, finally most staff wanted more training to be done that

would improve their service delivery.

5.5 Recommendations

In this sub-section recommendations are provided. These are provided in terms of

recommendations for improvements and recommendations for further studies.

65

5.5.1 Recommendations for improvement

5.5.1.1 The effect of devolution on hospital infrastructure

The study recommends that county health facilities need to improve their infrastructure in

terms of having well maintained equipment, purchase of specialized equipment so as to

restore public perception of good quality care and achieve devolution goals on

improvement of primary health care facilities. The equipment should be in good working

condition and counties should consider having designated units for repair and maintenance.

Public health technicians who were trained to maintain physical infrastructure should be

hired and the minimum infrastructural standards should be met by the county health

facilities.

5.5.1.2 The effect of devolution on access to health services

The study recommends that that county health facilities should increase their catchment

area to be able to serve a wider population also the health facilities should be distributed

equally in a manner that a facility is not overwhelmed while the other serves a few clients.

More funding needs to be allocated to purchase of medicines, equipment and maintenance

of buildings. This can be done by improving county health facility budgets through

expanding their source of income and not entirely depending on main government and

county government.

5.5.1.3 The effect of devolution on healthcare workforce

The study recommends hiring of more workers to address the shortage of healthcare

workforce in healthcare facilities. This can also be done by emulating best practices where

non-professional people can be trained to provide basic health care management in terms

of education, support treatment for HIV, deliver prescribed medicines and others, freeing

up specialized medical staff to perform more complicated procedures. Also, because of

low morale by health workers’ county health facilities should have various incentives to

attract and retain them, such as giving risk allowance, provision of bonuses, among others.

5.5.2 Recommendations for Further Studies

More case studies should be done on the other counties to ascertain whether there has been

improvement on county health facilities with the advent of devolution. It is also critical

that future researchers investigate the impact of county funding on devolution of health

66

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APPENDICES

Appendix 1: Introduction Letter

70

November, 2016

Dear Respondent,

REF: REQUEST FOR RESEARCH DATA

I am a Master of Business Administration (MBA) student at the United States International

University, Nairobi. I am required to submit as part of my course work assessment a

research project report on ‘the impact of devolution on healthcare systems’. The study

uses county Healthcare facilities in Nairobi and you have been selected as one of the

respondents. I kindly request you to fill the attached questionnaire to generate the data

required for this study. This information will be used purely for academic purpose and

your name will not appear anywhere in the report. Findings of the study shall upon request

be availed to you.

Your assistance and cooperation will be highly appreciated.

Thank you in advance.

Truphena M. Gimoi (Researcher)

Contact : 0723 593571

Appendix 2: Questionnaire

This questionnaire has been designed to collect information from selected staff of county

Health facilities and is meant for academic purposes only. The questionnaire is divided

into three sections. Please complete each section as instructed. Do not write your name or

71

any other form of identification on the questionnaire. All the information collected from

the questionnaire will be treated with strict confidentiality.

Part A: General Information

Kindly answer all the questions either by ticking in the boxes or writing in the spaces

provided.

1. Department or branch:-------------------------------------------------------------

2. Position in the organization: Clinical OfficerMedical officerPharmacistMidwife

Laboratory technician AccountantNurse Health Information officer

Procurement officerother (specify) …………………………………………………..

3. Level of education: Diploma Bachelor’s degree Master’s degree

4. Your gender: Male Female

5. Your age: 20-30 years 31-40 years 41-50 years Over 51 years

6. The years you have worked in the organization: Less than 2 years 3-5 years 6-8

years Over 9 years

Part B: Hospital Infrastructure

7. Are clean toilets or latrines available for staff and patients/clients?

Yes No

8. Do you have a protected placenta pit?

Yes No

9. How does this facility finally dispose of sharps waste, such as needles or blades or what is

the final disposal process for filled sharps boxes in this facility?

Burn in incinerator Open burning Dump without burning

Remove offsite stored in covered containerNever have sharps waste

Other (specify) ……………………………………………………………

10. Does this facility have a generator for electricity? This may be a back-up or stand-by

generator.

Yes No

11. What is the most commonly used source of water for the facility?

72

Piped into facility Public tap Borehole Protected spring Unprotected

springRainwater others specify

12. Do you have communication facilities(e.g. phones, two way radio)

Yes No

13. Is there ever access to email/internet within the facility?

YesNo

PART C: ACCESS

14. Do you have an estimate of the size of the catchment population that this facility serves, i.e.,

the target or total population living in the area served by this facility? How many people is

that?

0-5,000people 5000-10,000people over 10,000people

15. What transport do you use during emergencies?

Ambulance Taxi Motorcycle others specify

16. What is the most common means of transport used by patients who are referred from other

facilities to this facility for emergency services?

Public car/bus Private car AmbulanceMotorcycleBicyclePeople carry/push or

pull patient. Never receive referrals don’t knowother (specify)

17. How much time does it take to for the patients to reach the health care facilities?

30 mins

1hour

Over 1hr

Don’t know

If more than 1hour what could be causing the delay?

…………………………………………………………………………………….

18. What is your source of funding?

73

Government Local Government Donors Pre-payment schemes NHIF

others specify

19. What was your budget for the year?

250,000-500,000500,000-1,000,0001,000,000-7,000,000Others specify

20. Is adequate funding allocated for:

Medicine Yes No

Equipment Yes No

Maintaining buildings Yes No

21. What is the state of medical equipment?

Very GoodGood Very bad Bad None

22. Has new equipment been bought since county government came into place?

Yes No

If yes please specify……………………………………………………….

23. Do you have a designated unit for repair and maintenance of equipment?

Yes No

If No, where are the equipment repaired?..........................................................

24. Does your health facility offer basic emergency obstetric care?(i.e. pregnancy, child birth

and the postpartum period)

Yes No

74

25. What happens to comprehensive emergency obstetric care which requires specialists?

Explain

………………………………………………………………………………………………

………………………………………………………………………………………………

26. Do you offer free maternity services?

Yes No

27. Do you have a labour ward

Yes No

28. Does this facility routinely provide inpatient care?

Yes No

29. Does this facility have beds for overnight observation?

Yes No

30. How many overnight or inpatient beds does this facility have?

Number of beds

31. What is the condition of your laboratory?

Very GoodGood Very bad Bad others specify

32. How often do you replenish your medical supplies?

Monthly Quarterly Half yearly Yearly others specify

33. How often is the store audited?

Monthly Quarterly Half yearly Yearly others specify

PART C: HEALTHCARE WORKFORCE

34. What is the total number of staff?

75

1-5 staff 5-10staff 10-15 staffothers specify

35. In your opinion would you say you are adequately staffed

Yes No

36. Do you receive continual medical educational activities?

Yes No

If Yes, which ones?

................................................................................................................................................

............................................................................................................................................

37. Do you do appraisal?

Yes No

After how long

Quarterly Half yearly Yearly others specify

38. What mechanisms are used for staff motivation?

Tea for staff Lunch for staff Awards Letters of appreciationTime-offother

forms please state No mechanisms for motivation

39. Do you receive promotion for an employee good performance or any form of formal

recognition?

Yes No

40. What is the criteria for promotion?

AppraisalsAcademic qualifications others Specify……………....................

76

41. Are there things related to your working situation that you would like to see improved,

can you tell me the three things that you think would most improve your ability to provide

good quality of care services?

Training more knowledge / updates more support from supervisor

More supplies/stock Better quality equipment Better facility infrastructure

More autonomy/ independence Emotional support for staff (counseling / social

activities) others(specify)

Circle only three items.

****Thank you for taking your time to complete this questionnaire****

Appendix 3: Sample size

1. KAMUKUNJI

1 EastLeigh H/C Location: EastLeigh Section 7 2

77

2 Biafra clinic Location: Biafra estate 2

3 PumwaniMajengo H/C Location: Gikomba Open air market 5

4 ShauriMoyo Location: ShauriMoyo estate shopping centre 2

5 Muthurwa Location: Muthurwa market/bus terminus 2

6 Bahati H/C Location: Bahati Estate 2

7 Jerusalem Clinic Location: Jerusalem estate 2

2. STAREHE

1. Ngaira H/C Location: Off Hailesellasie Avenue, next to government

press

2

2. Rhodes Chest clinic Location: Ngaira health centre, next to

government press

2

3. Ngara H/C Location: Park Road 2

4. Kariokor Clinic Location: Opposite Ziwani shopping centre 2

5. Pangani Clinic Location: Pangani estate 2

6. STC Casino H/C Location: Off River Road 2

7. Huruma Lions H/C Location: Huruma Estate, next to Huruma grounds 2

8. Lagos Rd. Disp. Location: Lagos Road, next Marble Arch Hotel 2

9. Mathare Police Depot Location: Mathare Police Post shooting range 2

3. KASARANI

1. Mathare North H/C Location: Mathare North estate 2

2. Kariobangi North H/C Location: Old Kariobangi estate 2

78

3. Kasarani H/C Location: Kasarani DC’s office 2

4. Kahawa West H/C Location: Kahawa West estate 2

5. Babadogo H/C Location: Babadogo road, Ruaraka 2

6. NYS H/C Location: National Youth Service H/Q, Ruaraka 2

7. GSU Hq H/C Location: GSU hqRuaraka 2

8. Kamiti Prison H/C Location: Kamiti 2

9. Ruiru PSTC Location: Ruiru prison 2

10. CID Hq’sDisp.Location: Nairobi Area Police Hq 2

11. GSU RuiruDisp.Location: Ruiru GSU camp 2

4. WESTLANDS

1. Westlands H/C Location: Westlands 3

2. Kangemi H/C Location: Waiyaki way, Kangemi 4

3. Highridge H/C (CLOSED)

4. Karura H/C Location: Kiambu rd. next to Muthaiga golf club 2

5. Lady Northey H/C Location: State House rd. 2

6. State House. Clinic Location: State House 2

7. Kabete Approved Sch. H/C Location: Kabete Approved Sch 2

8. State Hse. Dispensary Location: State Hse Girls school 2

9. Lower Kabete Location: Lower Kabete 2

10. MjiwaHuruma Disp. Location: MjiwaHuruma, Runda 2

11. KARI 9Muguga) H/C Location:Muguga, Naivasha Road 2

79

12. Waithaka H/C Location: Waithaka suburb 2

13. Riruta H/C Location: Riruta shopping centre 2

14. Ngong Rd H/C Location: Karen 2

15. Woodley Clinic Location: Woodley estate MugoKibiru rd. district

facilities satellite clinic

2

16. Dagoreti Approved Sch. h/C Location: Dagoreti Approved Sch 2

17. Langata H/C Location: Otiende estate 2

18. Jinnah Clinic Location: Langata 2

19. Karen H/C Location: Hardy, Karen 2

20. Kibera DO H/C Location: DC’s office 2

21. Langata Women Prison H/C Location: Langata Women Prison 4

22. Nairobi West Prison H/C Location: Nairobi West Prison 3

23. Uhuru camp H/C Location: Uhuru AP camp 2

24. Kibera DO H/C Location: Kibera slums 2

25. KiberaAmref H/C Location: Kiberalaini Saba 2

26. GSU Kibera H/C Location: GSU Kibera quarters 4

5. EMBAKASI

1. Kayole 1 H/C Location: Kayole 1 estate 2

2. Kayole II H/C Location: Kayole II estate 2

3. Umoja H/C Location: Umoja II estate 2

80

4. Embakasi H/C Location: Embakasi village 2

5. GSU Embakasi H/C Location: GSU Training School 3

6. APTC Embakasi H/C Location: APTC Embakasi 3

6 NJIRU

1. Dandora 1 H/C Location: Dandora 1 estate, Komarok road 2

2. Dandora 11 H/C Location: Dandora II estate 2

3. Njiru H/C Location: Njiru shopping centre, Kangundo rd. 2

4. Kariobangi South Disp.Location: Kariobangi South estate 2

7. MAKADARA

1. Makadara H/C Location: Jogoo rd., Hamza estate 3

2. Mbotela Location: Mbotela estate, jogoo rd. 3

3. Jericho H/C Location: Jericho Lumumba estate 3

4. Hono Clinic Location: Hono Crescent Jericho 2

5. Ofafa 1 Clinic Location: Ofafa 1 2

6. Maringo Clinic Location: Maringo 2

7. Loco H/C Location: Nairobi Railway Station, Industrial area 2

8. MOW Dispensary Location: MOW sports club 2

9. Kaloleni Dispensary Location: Kaloleni estate shopping centre 2

10. Railway training Institute (South B) Dispensary Location: Railway

training Institute (South B)

2

11. South B Clinic Location: South B, next to shopping centre 2

12. Police Band Dispensary Location: South C 2

81

13. LungaLunga H/C Location: LungaLunga informal settlement 2

14. Nairobi remand Home H/C Location: Industrial area 3

Totals 169